Managing Diabetes. Jeffrey A. Bennett
because of their overconsumption. Although people with type 2 sometimes have more control over their body, it is an oversimplification to assert that there is a single causal agent of diabetes or that it can be easily remedied. It is also a mistake to assert that all people who are classified as overweight will develop diabetes, as the vast majority of people, including those labeled obese, never will.21 Chapter 2 deals explicitly with this stratification system, examining the ways shame shapes surveillance and limits productive intervention strategies for addressing diabetes rates.
Diabetes’s denominations are not wholly structured around the stark binary between types 1 and 2. As scientific understandings of the endocrine system have evolved, so too has the volatile and fluid role of glucose in the body. Many people, for example, live with latent autoimmune diabetes in adults (LADA), which is sometimes referred to as type 1.5 diabetes. In LADA, the presence of antibodies negatively engaging the body exists, as it does with type 1, but the onset period is slower. The pancreas is still producing some insulin, but injections are customarily needed within six years. Still other people live with forms of monogenic diabetes, also known as mature onset diabetes of the young (MODY). This rendition of diabetes is typically diagnosed in people younger than 25 who experience (often undetectable) hyperglycemia that never progresses toward ketoacidosis. Researchers have also begun studying the connection between Alzheimer’s disease and insulin resistance, sometimes referring to it as “type 3” diabetes. Scientists theorize that insulin deficiency to the brain causes neurodegeneration that catalyzes Alzheimer’s. The relationship between Alzheimer’s and diabetes has been circulating in medical circles for at least a decade and could help to advance knowledge about the biochemical exchanges between diabetes and various parts of the body. From a cultural perspective, it is imperative that we monitor the rhetorical development of “type 3” diabetes and its potential affinities with type 2. It is entirely possible that blame might be foisted on to people with Alzheimer’s for their diagnosis, as it has for other variants of diabetes. For better or for worse, new forms of knowledge are always articulated to previous epistemological tendencies that rest outside the confines of medical taxonomies.
Finally, although gestational diabetes receives the least amount of attention in this text, it certainly deserves mention. The disciplining that occurs during pregnancy, especially for women with any trace of sugar irregularity, promulgates significant parallels with rhetorics of excess, shame, and projections of the productive body. The American Diabetes Association reports that doctors do not know why some women develop gestational diabetes and others do not. Scientists hypothesize that hormones produced by the placenta spark insulin resistance, initiating hyperglycemia in expectant mothers. The condition tends to be temporary and does not stay with women after they give birth. Gestational diabetes can create problems for the fetus (including a higher risk for type 2 diabetes later in life) but is ordinarily treatable. Nonetheless, meaningful intersections can be found between diabetes and pregnancy: Pregnancy is perennially couched in terms related to personal responsibility and the role of the mother as a “protector” above all other things. Likewise, women’s bodies are monitored during pregnancy and they are judged when they eat the “wrong” foods, drink any trace of alcohol, or consume caffeine. The body is rigorously surveyed, not necessarily by the mother herself, but by loved ones, acquaintances, and even strangers. Moralizers regularly police the bodies of pregnant women and people with diabetes, and combining them produces an ominous form of public supervision.
The disciplinary tendencies that accompany diabetes highlight the degree to which management has been couched in and grounded by neoliberal conceptions of agentic subjects and their relationship to biopolitical performances of governmentality. That is, undergirding the logic of diabetes care regimens, there is an assumption of a person who has the ability to make particular, if undefined, choices in order to achieve an abstract goal of control. These impressions of diabetes have been given much attention in studies that focus on the clinic, a site that not only has generated an impressive amount of medical data, but one that has nurtured diabetes’s public character and the lexicon we tend to adopt when discussing it. Iterations of management as a public disease do not rest apart from those that are situated in the microcosm of the clinic. Rather, they are mutually informative, offering insights into the development of public narratives about diabetes and its disparate forms.
Management: A Paradigm of Personal Agency
In the early twentieth century, chronic medical conditions killed approximately one-fifth of the US population.22 People were more likely to die from pneumonia, tuberculosis, or diarrhea than they were from diseases such as diabetes. Thanks to advances in science and medicine, many of the environmental and infectious agents that once plagued us have been eradicated, helping to extend the human life span by nearly three decades. As a result, chronic conditions now claim the lives of nearly 80 percent of the population.23 This dramatic transformation in public heath necessitated a vocabulary for contending with the everyday consequences of chronic diseases, and there is no paradigm more ubiquitous than that of “management.” Turn on the television and you’re bound to see commercials for COPD medications that spotlight management as a central concern.24 Anti-obesity campaigns continually stress exercise regimens and dietary management to maintain wellness.25 Management is invoked in public rhetorics dealing with depression, diabetes, epilepsy, asthma, fibromyalgia, coronary artery disease, hemophilia, chronic fatigue syndrome, and erectile dysfunction.26 Even diseases that were once classified as exclusively infectious, such as HIV, are now regarded as chronic and manageable.27
The amalgamation of conditions outlined above illustrates the fungible nature of management and its plasticity in public rhetorics about health and medicine. In each instance, the framework of management endows patients as recipients of technological knowledge and medical aptitude. Medical epistemologies of the past envisioned the body as a machine in need of repair and bestowed the locus of expertise to physicians who could rehabilitate it. Today’s conceptions of management, conversely, assign direct agency to people living with disease.28 Such regimens permit those who know their bodies best to steer quotidian treatments and enhance their quality of life, as long as they have access to lifesaving resources to stay well. Zoltan Majdik and Carrie Ann Platt argue that management fosters “a perspective that connects potential loci of action and choice to domains lay audiences feel comfortable with and competent in.”29 The expertise imparted to individuals, however, can create equally daunting problems. Many scholars have warned that management incites an obligation to conform to the imperatives of public health mandates and those who craft them.30 Patients are increasingly responsible for adopting the knowledge furnished by medical and state authorities, performatively rehearsing scripts that appear self-evident in their execution and effect.
Blurring the boundaries of medical aptitude between patient and physician suggests management is not easily studied using only biopolitical theories of governmentality or neoliberal projections of personal agency, even though many works engage one or both of these to investigate management’s conceptual scope. Michel Foucault’s works on discipline and surveillance are certainly useful for contemplating the reach of medical norms, but so too are his notions of resistance, technologies of the self, and the development of moral personhood. Attempting to determine where the clinic door ends and the currents of everyday life begin is a knot that is not easily untangled. William Donnelly’s call for “clinical arts” and Arthur Kleinman’s push for “meaning-centered” notions of care both reflect the ongoing conceptual messiness of communicating about illness by acknowledging the reach of medicine into quotidian practices without relinquishing the ways people appropriate, articulate, nuance, and omit medical directives from daily routines.31 In a similar vein, Peter Conrad has famously noted the ascendance of medicalization, a process that seeks to impart increased individual control over disparate conditions through technological and pharmaceutical intervention.32 Even as diabetes is assuredly a medical reality, management has followed the path of medicalization, becoming a catchall for diffuse bodily treatments and maintenance. Navigating the fictive extremes of structurally determined public health mandates on the one hand, and patients with unfettered agency to make “the correct” choices on the other, requires a focus on the meaning-making practices of people with diabetes and the unexpected, sometimes convoluted, ways they process ideas associated with management. Numerous scholars have attempted to gauge these formations by probing one