Medication-use narratives on the margins: Managing type 2 diabetes without medical insurance 1

Jenny Epstein


The increasing use of pharmaceuticals to manage all aspects of everyday life has prompted scholars to examine how this use shapes relationships between body and self. The myriad ways people use medications, particularly for type 2 diabetes mellitus (T2DM)2, and how medication use can change over time is a process I have observed over decades as a clinical pharmacist. In this chapter, I use this experience and expand on previous work to examine how pharmaceutical use mediates particular spatial and temporal forms, which in turn shapes relationships between body and self. This spatiotemporal lens allows new avenues to examine how the social spaces humans design and live within (including bodies) shape the ways we conceive and take care of ourselves.

As a mass-produced technology, pharmaceuticals are designed (ideally) to deliver uniform and mechanically predictable effects with every dose taken. In turn, the bodies they work on become (again ideally) equally uniform and predictable, inseparable from routinised medication schedules and greater regimentation of the user’s daily life. In contrast, I show how successful diabetes control comes from creating social space that is local, unique and rooted in embodied experience. Focusing on the spatial and temporal forms provides a unique insight into the ways alienation between body and self is both produced and resisted through pharmaceutical use. It moves the focus away from individual psychology or labels of‘non-adherence’ and studies how people creatively construct (or struggle to construct) medication self-care practices within the macro forces of modern capitalism.

I use Henri Lefebvres (1991, 1979) conception of social space as a way to more fully grasp how a global, mass-produced technology like pharmaceuticals shapes everyday life. Composed of heterogeneous forms of space and inseparable from time, social space is not simply a detached backdrop or passive frame for human practice, but plays an active role in all aspects of cultural production. Lefebvre used spatial and temporal forms as a way to understand how power is produced and resisted in modern capitalism, with a particular focus on the production of and resistance to alienation in everyday life. In what Lefebvre defines as the ‘abstract’ social space of modern capitalism, relationships between things are made measureable, uniform and interchangeable; time becomes predicable

Medication narratives in Type 2 diabetes 29

and routinised. Here, I apply this theoretical frame to ethnographic research that took place in Tacoma, WA, USA. I use life-story narratives of working-poor residents living with T2DM as a way to illustrate how less obvious, but powerful social forces shape the ways people construct medication practices over time.

Lefebvre (1991) defines the ways the body is quantified through self-measurement and the ways time is routinised as ‘abstract space’, a social space that increasingly dominates everyday life, mediated through the global flow of commodities, such as pharmaceuticals. Through this mediation, relationships between body and self are made interchangeable, impersonal and measurable -mirroring the qualities of social relations (and social space) that dominate our larger social world. This process orders self-care practices so that the necessity for meaning-creation and self-contemplation become hidden. Instead, technical skill, self-measurement and routinisation are deemed essential qualities of self-care.

Mastering T2DM self-care is the transcendence of routine through meaning-creation. Methodologically, diabetes life histories uncover how this process unfolds over time. Analysis of these life histories showed that the ability to create new meanings was an essential piece of the struggle to make life-saving change worth the effort. The data I collected shows people slowly coming to terms with using (or not) medications, so managing their symptoms meant profoundly rearranging existing ways of understanding embodied experience. Most importantly, the struggles people experienced centred on what I argue is an underlying contradiction of long-term medication use: namely, the self-measurement, routine-creation and technical monitoring skills, which form the foundation of T2DM self-care protocols, exacerbate an already existing sense of disconnection many people feel towards their own bodies and health.

In this chapter, 1 explore how these principles apply to pharmaceutical use and how, as a mass-produced technology, pharmaceuticals shape the ways people must rethink their bodies and everyday schedules. With this framework in mind, I focused on the following questions: What patterns can be identified surrounding diabetes medication use over time? How do these patterns correlate to practices of self-care and ultimately relationships between body and self? Who had to make the greatest changes and why? What were the motivators and barriers to self-transformation?

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