Images.
Type 2 diabetes, on the other hand, is often diagnosed in people who are older and sometimes overweight. Whereas type 1 is characterized by a lack of insulin, people with type 2 either do not produce enough insulin or their cells lose sensitivity to insulin and ignore it.19 This form of diabetes is typically controlled through oral medication, although type 2 can also necessitate insulin if the pancreas disengages fully from its normal functions. Type 2 diabetes constitutes about 90 percent of all cases and is most lethal because it can remain undetected for years. Once associated with wealth and whiteness, type 2 diabetes has evolved in disparaging fashion to be affiliated with minority and low-income communities. A metonymic correlation is frequently crafted in media outlets among race, consumption, and the moral failings of not rigorously maintaining the body. A widely circulated photo of an African American woman whose head is cropped out of the frame and who is utilizing a cane as she walks past a McDonald’s points to the problematic representations that are imparted about type 2 diabetes. The line of sugary drinks and high-calorie meals metaphorically dissolves into the woman’s body, drawing a straight line between consumption, responsibility, and disability. And while the products are on full display, the woman herself is dehumanized: She literally has no head. As such, all that audiences can presume to know about her identity is made in association with the visual referents around her. When coupled with the headline, “Diabetes Could ‘Bankrupt the NHS’ After 60% Rise in Number of Diabetes Cases, Charity Warns,” this woman’s control is imagined to be out of bounds, affecting not simply her, but the body politic as a whole.
Culturally then, these two forms of diabetes are distinct because of the blame assigned to people with type 2.20 As noted earlier, narratives commonly adopt an accusatory tone, contending that if a person simply would have eaten less, managed their diet, or exercised more, they would not be struggling physically and emotionally. Whereas people with type 1 diabetes have an onset period of several weeks, signaling the decreased capacity of the pancreas, type 2 develops at a glacial pace, leaving most cases undetected for years. As a result, in the cultural schema of diabetes, people with type 1 are widely cast as victims, while those with type 2 are positioned as deserving of this outcome 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
