For 14 years I have lived a hamfistedly biopolitical life, in which all food is quanta and my blood talks in numbers.
The trouble with comparing a poet with a radio is that
radios don’t develop scar-tissue.
—Jack Spicer
For most of its history, diabetes has been about piss, death, and shame. Especially piss. Things are marginally different now, because now the primary metrics and metaphors of diabetic life turn around blood. Blood as number or proportion. Blood as an occasion for sugar. Blood over the long term. Blood to be tested and slowly placed at the heart of all affect, like a concept. Blood that gets everywhere.
I’ve found that I no longer say I have low blood sugar, like I did at first. I just say, I’m low, which doesn’t mean sad or blue. It means <70 mg/dL, as opposed to <55 mg/dL, which itself means I am a fever made of glass and on the way to a buzzing nullity in place of symbolic thought (35 mg/dL). There’s a basic synecdoche to diabetic life, where our blood not only stands for the whole enterprise of a body across time, but also winds its way into every pocket1 of that body’s life.
For my own experience at least, it is not sickness that sops up the personal, the incidental, and the private. We ourselves become the substance of illness, a sponge into which busy paths of world are drawn in and squeezed out. A substance full of holes, teeming mid-point for a set of processes that far exceed us. That is my most constant tactile experience: The sensation of being permanently porous, a surface from which small beads of blood are squeezed at least four times a day, and through which is injected a liquid that smells like pig leather.
This property is there in the word itself: Diabetes comes from the Greek word for siphon, in the sense of “that through which is passed.” It means something that is not itself a vessel, not a container, merely a medium of circulation. But the conditions of experience I’ve described are themselves extremely recent, as insulin injections emerged in 1922, and blood-based glucose testing came to market in 1970. Before the blood test, testing meant measuring or examining urine, and before insulin injections, being diabetic meant a death sentence of variable length. Type 1 diabetics, like me, died fast, our coma breaths reeking of rotten hay. Type 2 diabetics died more slowly, some surviving due to food scarcity imposed either by diet or war and famine. And given that there was no operative treatment, diabetics pissed all the time: They were siphons through which water and their own bodies poured, gallons a day.
The reason is simple enough. Insulin is the hormone that regulates cellular absorption of glucose. Type 1 diabetics have no insulin production, because of an autoimmune attack that destroys the responsible cells. Type 2 diabetics have diminished insulin production or sensitivity. When too much glucose remains in the blood and is not absorbed into cells, the kidney cannot reabsorb that glucose. It gets pissed out. The increased sugar ramps up the osmotic pressure of the urine, which makes it all the harder for the kidney to reabsorb any liquid, which spurs on increased urine production and so the cycle begins. You develop a “fatal thirst,” as the body pours out all its moisture into upwards of fifteen liters of urine a day. You waste away, because unable to get energy from sugar, the body starts consuming all of its energy reserves, its fat. Things get worse from there. Untreated, you die. If you manage to hold on for a while, you go blind, your organs fail, you cease being able to heal any sores. Your limbs turn first numb, then necrotic, and require amputation.
Frequent urination is therefore not cause but symptom, an indication of failure on a far more microscopic level. Still, it was visible and specific, and hence, it became the index for the illness, which was treated for most of its history as a variant of polyuria (excessive urination) in general. Therein the name, the “passing through,” given by Apollonius of Memphis in 230 BC, before getting its unique qualification from British physician John Rollo in 1797: mellitus, meaning “honeyed,” because the urine of untreated diabetics tastes, in the words of Avicenna, “wonderfully sweet.” Etymologically at least, to be a diabetic is to be a honeyed siphon. The earliest known medical description of the disease came from the Ayurvedic tradition, in Sushruta’s sixth century BC Sushruta Samhita, where diabetes appears as madhumeha, or “sweet urine.” So for most of its history, this combination of constant urination and unbearable thirst—Zhang Zhongjing termed diabetes “the malady of thirst”—was grasped as the condition itself. It was “the pissing evil” (Thomas Willis), an evil that appears especially potent in the writings of Aretaeus, the West’s first extended account of the illness. There, what pours through the siphon is not just excess (and excessively sweet) urine but also the patient herself: Aretaeus sees a “melting down of the flesh and limbs into urine.” In Galen, it’s a “urinous diarrhea,” for which he prescribed the first of medical history’s truly terrible proposals for diabetic relief: vigorous horse-riding. Oh, you cannot stop making water, to the point that it feels like your body exists as a mobile spout through which the world is poured? You should get on a horse. Make it bounce around a lot.
The continual emphasis on urine was hardly unique to diabetes, as it belongs to a wider history of the alternately derided and lauded “pisse prophets,” in the double sense of those who sought to detect all the body’s ills through urine alone and those who were more literally “uromancers,” divining the future through the frothy bubbles of a piss pot. This deep emphasis on uroscopy remains unsurprising, in part because of the continued influence of a Galenic (i.e. “humor-based”) conception of the body, in part because it was a visible, tangible, and tastable symptom (the body’s own “infused liquor,” according to Willis). It could be examined, measured, and discussed without opening up the infection-prone body through which it had passed.
Such metrics would become more sophisticated, but the plagued lives of diabetics did not change substantively from Sushruta’s diagnosis until the “discovery” of insulin in 1922. “It seems a most hard thing in this disease to draw propositions for curing, for that its cause lies so deeply hid, and hath its origin so deep and remote,” Willis lamented. The link to food was evident early on in this history, so various diets were tried, including, in unfortunate news of medical paths not subsequently followed, one of the most successful pre-insulin injection remedies: a diet consisting primarily of cannabis and animal protein. (The Victorian British threw opium into the mix as well, which at least made the quantitatively brief but qualitatively expansive hell of diabetic life slip free from its sense of time.) A number of physicians did settle on diets that grasped how diabetics do much better consuming as little sugar, starch, or grain as possible, but their suggested replacements tended toward a sort of Atkin’s Unchained. The lunch menu of Rollo’s influential 1797 book An Account of Two Cases of the Diabetes Mellitus, for instance, was: “Plain blood puddings, made of blood and suet only.”
But while Rollo’s insight was not rare, it was by no means broadly adopted. In the diabetic equivalent of Hostel, French doctor Pierre Piorry pushed a “sugar feeding” diet, based off the idea that diabetics needed huge quantities of sugar to make up for all that was pouring out of them by the pint. The results were as ghastly as one would imagine. The litany of torturous cures is long and bleak. As Elizabeth Jane Furdell sums them up, “the afflicted were bled, blistered, purged, doped, sweated, belted tightly around the waist, submerged in various liquids, and rubbed with disgusting ointments.” John Pechey, a seventeenth-century British physician and extremely nasty piece of work, forced his patients to drink steel filings.
None of this made any difference. Diabetics died as they lived, their bodies feeding on themselves, as open to the world as unplugged drains. They lived in shame. Aretaeus himself notes that a diabetic’s life is not just “painful” but also “disgusting”: “But by what method could they be restrained from making water? Or how can shame become more potent than pain?” That’s the point precisely: with diabetics, it simply can’t. One cannot “hold it,” because one becomes siphon. In Liverpool doctor Matthew Dobson’s case notes, we read of Peter Dickonson, who pissed 15 liters a day. The special quality of diabetic piss, the one that left physicians in wonder, was that when it evaporated, it left behind piles of sugar. The body becomes a small refinery. Dobson tasted the white cake left behind and declared that it could not “be distinguished from sugar.” Francis Home made beer from it. A diabetic Modest Proposal isn’t hard to fathom, yet our history is not that of our busted bodies being put to use processing sweets for those who can consume them, our eyes first jealous then blind. It is a history of 11 pints of urine a day “stiffening his clothes when it falls upon them,” of the “rude crystallization” of diabetic urine left on a woman’s dark shoes, of sugar snowflakes on those of men, crusted white on black worsted stockings. Underwear piss-stiffened into candy cane knives. A slop pail beneath the bed, because a bedpan just didn’t cut it. That pail being drained in the night, by one without water and so thirsty that he drank his own urine.
***
When I was 17, I was living on a self-sustaining farm/school in Maine, which made my wholly typical and crippling teenage melancholy, soon to blossom into weapons-grade depression, all the weirder. Listening to Elliott Smith’s “Christian Brothers” on repeat while milking a wart-uddered cow at 5:30 AM during a blizzard, already on my second dire epiphany of the day, sums it up plenty. Still, other than a permanent loathing for what was supposed to constitute Saturday night there (enduring a man in a chunky sweater croon James Taylor songs), I was healthier than I’d ever been: straight-edge, vegan, eating food I helped grow myself, and fit as hell from chopping wood.
I was drinking a lot of water, but that entire scene of those who can identify a tufted titmouse by sound alone tends to be obsessed with “hydration.” It only slowly dawned on me that this went far beyond that: I was a set of channels through which water was turned into the only marginally different. I relieved myself outside cabins, on them, out their windows. I startled titmice blundering through trees. I was bursting, always. I barely made it, always. But like my wasting away in the same months, which I chalked up to the wood chopping—the transformations of bodies are always more dramatic to those who aren’t stuck with them.
My changes were clearer to my parents, for instance, and my mom especially. Her brother Rob was a gentle bear of a man, a big guy, deep into Harleys with a beard to match. He was also a diabetic, from the decades when you could never know your numbers exactly, where the whole game was imprecise.
***
The crux of shame is that we are never enough unlike ourselves. We are ashamed because we can never stray far from the self’s terrified inertia. For diabetics, this happens when others see us become partial to ourselves, when a single strand of our life—its pure metabolic need—swallows the rest of it, yet without a clear demarcation of having happened. Unlike werewolves, diabetics get feral and sugar-berserker without obvious external signs. It creeps up on us, on those around us. And then the world, all tremulous and adrenal, shrinks to its simplest. When we are low (like werewolves, diabetics are always plural, because we cannot separate ourselves from the long paths of scarcity and infrastructure, shame and empire), we come much closer to literally stealing candy from a baby than the expression ever intended. We stare with obscure hunger at apple-cheeked little shits scarfing Smarties in their strollers. We dream of gorging on the donut-rich blood of one type of bro, on the Paleo pancreases of another. Always plural, we nevertheless have absurdly singular senses of time, charted by little metabolic tides that constantly move, setting patterns of affect indifferent to whatever we are doing. We snap out of the blue, flags with their own private wind. We stop fucking to crouch naked in front of the refrigerator, prying honey from the jar with sticky fingers like a porny Winnie the Pooh. We pass out on the floor. We seizure. We get low.
These peculiar shames are dwarfed, though, by the major form of shame that runs through diabetic history, that of blaming of individuals for conditions globally imposed on them. It’s a shame we might simply call class if it wasn’t so shot through with other determinations, especially with the contemporary racial demonization of diabetes. The split structure of the disease has always lent itself to this. Because Type 2—“slow diabetes” (Blackmore), “long diabetes” (Whytt)—has been linked, from the first recorded accounts on, to certain kinds of diet and obesity, it easily opens up charges of fault and blame.
There are, of course, various attempts to lay the blame with less edible forms of morality: Gilbertus Anglicus, in 1320, saw the cause of diabetes in overwork or in “to moche medling [too much meddling] with women.” John Elliotson, a late-eighteenth and early nineteenth century physician, was surprised that a diabetic who died under his care claimed to have never been sexually involved with a women. William Prout, a contemporary of Elliotson, noted with interest that some of his middle-aged patients “confessed they had been addicted to masturbation from early youth.” Pechey—the steel filings doctor—thought it “invades those that are of a lax and crude habit of body.” Grief was a supposed factor, as was anger and other forms of emotional stress. For Robert Saundby, writing in 1897, “the disease is much more common among the educated than the uneducated classes—that is it occurs chiefly among those whose nervous systems undergo more wear and tear.”
Obviously wrong as this is—in which of all possible worlds do the “educated” undergo more wear and tear, nervous or otherwise, than those who the educated employ, colonize, govern, and imprison?—the class-based inflection isn’t. Because for most of its recorded history, Type 2 diabetes was overwhelming the province of those with access to excess calories. They alone had consistent means to consume refined sugars, processed flours, and butter to drench it all in, while those who labored to provide it lived, in the European context from whose medical history I’m drawing, on subsistence diets based on whole grains and vegetables. Thomas Cocke published Kitchen-physick or, Advice to the Poor in 1675, urging prudent diet, but the “poor” had then, as they have now, extremely limited choice about what kind of food to consume. Type 2 diabetes was primarily a toxic luxury that the rich alone could afford and which they might well avoid, if only they took some culinary hints from lower rungs on the social ladder.
In this regard, most of the pre-insulin history of diabetic “advice” centers on urging temperance and permanent fasting, as in the counsel of John Wesley, the founder of Methodism and a diabetic: “Abstain from all mixed, high-seasoned food. Use plain diet, easy of digestions, and this as sparingly as you can, consistent with ease and strength.” Other advice was even plainer: having witnessed that during the 1870 siege of Paris, glucose disappeared from the urine of some patients because they were starving, Apollinaire Bouchardat urged diabetics to simply “eat the least that is possible.” (In other words, diabetic life does best in a permanent state of siege.) For those with rich patients, attempts to reform consumption often took the form of chiding a bit of good-natured over-indulgence, the blame laid especially at the feet of the epoch—“our age given to good fellowship and guzzling down of unallayed wine” (Willis)—rather than on the decisions of those with the time and cash to actually choose what they ate
For the poor: shaming and attempted confinement. In the British Medical Journal of 1865, one reads that enforcement of diet “may be comparatively easy to effect in private practice [i.e. with those who can afford it]; but in the case of the poor, especially the outpatient poor, who cannot be made to understand the necessity of abstaining from bread, potatoes, apples etc., it becomes a very difficult task to teach them what to eat, drink and avoid.” The only thing one could do, some doctors suggested, was to lock them up: “The gentlest exercise only to be permitted: but confinement to be preferred” (Rollo). Otherwise, they would “commonly trespass, concealing what they feel as a transgression on themselves” (Rollo) or indulge “clandestinely in the most injurious of the prohibited articles of food” (Donkin).
***
The situation is manifestly different now. Diabetes is a slow-motion pandemic, one of global modernity’s signature ills that has moved relative infrequency to a permanent fixture. In 1897, Saundby called it “one of the penalties of advanced civilisation.” Saundby wrote this at the exact mid-point of W.P.D. Logan’s study of English and Welsh deaths over a century (1848 to 1947). The study showed that general mortality from diabetes rose and rose, even after the introduction of insulin (in 1922), only declining during wartime deprivations when there simply weren’t enough carbohydrates available to spike the blood. In the second half of the twentieth century and into the twenty-first, the disease grew unchecked. In the U.S., the national rate of diabetes grew 49 percent in a 10-year span alone, from 2003 to 2013. Among American children, Type 2 diabetes—previously associated almost exclusively with much older populations—rose 30.5 percent in just eight years (2001-2009). It is hardly limited to the U.S.: In China, it has risen from 7 million in 1994 to 114 million as of 2013, wildly eclipsing previous estimates of 45 million by 2020. Globally, the total number of diabetics will double by 2030, leading to an estimated 10 percent of the world’s population diagnosed as diabetic. Diagnosed, we should stress, because for major portions of the world, the bloom of Type 1 and especially Type 2 diabetes is itself a silent creep: it’s estimated, for instance, that 78 percent of diabetics in African nations are undiagnosed.
Just as dramatic as this still accelerating proliferation of diabetes is the total inversion of its class dynamics. Type 1 remains nominally random, although clearly bound to family lines (and itself increasing, indicating long-term environmental and dietary effects). Type 2, however, has entirely shifted from a deadly affliction of the mostly rich to a devastating and diffuse biopolitical violence against the entirety of the global poor, especially the non-white. In the U.S. alone, for instance, incidence of diabetes sketches an extremely literal map of colonial expropriation and domination: indigenous populations have fully twice the rate of diabetes (15.9 percent) as whites (7.6 percent), with “non-Hispanic blacks” and “Hispanics” closely behind (13.2 percent and 12.8 percent respectively).
Why this proliferation and this demographic specificity? Across the twentieth century, capitalism nominally conquered scarcity, reducing famine to something its champions could claim as isolated aberrance in zones of the world deemed “unstable.” Yet it conquered that scarcity through monocropping, adulteration, and padding out its food, flooding markets with variations on extremely cheap, easily available, near unspoilable, and heavily processed food that technically answers caloric need but, in the long run, wreaks sheer havoc on the body. The proper name of that havoc is diabetes. And in this way, diabetes is, more broadly, itself just the name for one particularly common variety of the brutal and repetitive intersections of individual bodies with a global circulation of commodities, energy, and pollution. This circulation results, and only can result, in the ruination of those bodies because its infrastructure and wealth was and is built with their stolen labor, because it exists for the purpose of reproducing a social order that would sooner kill its humans than rearrange itself.
What haven’t changed, despite this social inversion of Type 2 cases, are the forms of shame—both shaming and feeling ashamed—that accompany dealing with your own body as the fallible, wretched, and painful site where this degradation and contradiction gets worked out, all the way to infection and beyond. Online diabetes forums are particularly striking spaces to witness this.
Like most medical (and weightlifting and RPG) forums, the signature for each post tends to be an arcane list of personal statistics (“DxT2: 1/26/2010: 6’2” 268lbs. A1C 7.8, FBG 266 A1C: 1/2010: 7.8 ; 6/2010: 4.7 ; 9/2010: 5.1 ; 12/2010: 5.2 ; 4/2011: 5.3 ; 9/2011: 5.3”), linked to the desire to make it to the unofficial “5 percent club” (a hemoglobin A1C long-term blood sugar reading under 6 percent), and lists of medications (“Metformin ER, Lantus, Novolog, Zofran for Gastroparesis, Gabapentin-Neuropathy, Zocor 40MG, Fish Oil 4000MG”). Amongst the impressive display of affective mutual aid, though, are extensive representations of shame. In one thread titled, “Anyone ever been ashamed when buying your meds etc…,” the poster writes,
Just curious if this is just me...but I am so ashamed that I am a Type 2 diabetic. Whenever I go pick up my meds or buy strips, I am thinking that everyone is thinking… “What a slob, she is costing everyone so much money, etc. Of course this motivates me to stay with my lifestyle changes...my goal is to be a skinny diabetic ...LOL! I know I don’t like telling anyone I am diabetic...unless they are close friends.
If you read across the threads, the same situation recurs over and over again, especially with Type 2s. For the Type 1s, whose illness is more cleanly (and socially) decoupled from individual histories of consumption, the primary moments of shame center around discomfort about injecting or bleeding oneself in public, being a general emotional nightmare, the consequences it could have for employment, or blacking out from hypoglycemia, which one woman frames in terms of “the walk of shame”: “the feelings of embarrassment and shame; the feeling that everyone is watching me to see if I will pull a repeat performance and pass out again.” Diabetic solidarity appears to founder on the rocks of blame, though, because while the forums are largely supportive, one sees hints of the kind of prejudice against Type 2s that extends far beyond the forums. One forum member, who has since been banned, writes that, “The motto for Type 2’s should be ‘Ask your doctor about how long you can expect to live if you don’t accept personal responsibility.’” That move is, at best, mean-spirited and wrong, and, at worst, classist, white supremacist, mean-spirited, and wrong. But even without such sniping, the barbs of shame are sunk deep, twisted by the posters themselves. “sometimes I’m bad in secret—I almost feel like an alcoholic must feel,” one writes. Another, at length:
I look in a mirror and see me looking back and think, “I can’t believe you did this to yourself!” Be it the four slices of pizza, the two heaping plates of pasta, or a bowl of M&M’s at my desk providing a steady carbohydrate drip. I did this [to] me. I was warned, but did nothing. To me, that clearly shows a lack of my self control and discipline. For that, I am indeed embarrassed.
None of this is helped by the fact that as far as recent research shows, one could in fact largely, if not entirely, reverse Type 2 with “dietary energy restriction” alone. Such research leads to the further excoriation of diabetics by celebrity doctors, like Dr. Mark Hyman, who writes of Type 2’s “bingeing on donuts and soda.”
But to even frame it in these terms, of what could be achieved with an “ideal” diet, entirely misses two points. First, and most obviously, the cost—monetary and time—of that ideal “restricted” diet de facto excludes the majority of those who have to deal with diabetes. Try and find diabetic-tolerable food, enough for a meal, for under $5 anywhere in Manhattan, that isn’t just a handful of protein powder and doesn’t require going 30 minutes (and $2.50 of transport fare) out of your way. It will become crystal clear that the entire discourse about “doing it to yourself” must be inseparable from much harder conversations about what is done to and through us by an indifferent, material, and very police-backed organization of space, race, gender, and wealth. Of course, if we all “cook our own meals,” a general management and deceleration of diabetes would be achievable. But the changes this would require, in terms of access to time, resources, and money for the populations most struck by diabetes, would be so thorough-going that they literally cannot be answered outside a situation of total social upheaval.
Second, to even enter the terrain of the counterfactual—what if “they” didn’t eat this way? what if we didn’t wreck ourselves upon ourselves?—is to fall into a trap of seeing sickness as natural, a direct line between a body and its subject. But sickness is not natural. It is always social and always historical, necessarily inseparable from forms of rule. The siphon through which the world streams is always bent by that world, long before we puke and piss, metastasize and rot, strike and coma. And diabetes—the condition of being a metric, extensive subject dependent upon the same circuits of production that make you sick to start—shows just how extensive that bending has become, reaching far beyond those who are technically diabetic. What else, after all, is the recent fetish for unnecessary biometrics—those Nike and Fitbit and whatever bracelets that sync to your phone and tell you how many calories you have burned—than a sort of generalized becoming-diabetic? For us whose days are numbered, in all senses of the word, this urge toward the quantitative is as familiar as it is horrifying. I have, for 14 years now, lived a hamfistedly biopolitical life, in which all food is quanta and my blood talks in numbers. Yuppies, it seems, just can’t wait to do the same.
***
I don’t doubt that sometime before Manhattan has gone and become New Atlantis, there will be a genetic advance that stimulates the reproduction of beta cells in the pancreas and “cures” diabetes. Or at least an artificial pancreas that doesn’t require a life of immunosuppressants. Diabetes, the world’s eighth largest cause of death, will technically be a thing of the past. And yet, it won’t. It won’t because the sickness is just one small stop in a situation that allows no such partial fix. Diabetes will exist, even after it is cured, because capital cannot both accumulate and overcome its necessary neglect for the majority of those who make it turn. The disease flourished so widely because the growth of capital requires and enforces a strict indifference to lives in particular. In an era where openly declared war has been exchanged for permanent crisis operations, it would be sheer gall to expect that a century and a half of industrial food production and distribution—the system that allowed capitalism to technically feed all while poisoning the many—will be overturned because of lives lost and costs to a medical system.
In many ways, diabetes is to the body as debt is to time. Neither was invented by capital but both expand within it, bloating tremendously in the most recent decades. Both turn around the mobilization of shame and the daily violence of living with what we are told are the fault of individual decisions. Both write themselves on and in the person: the frayed nerves of debt, the missing limbs of diabetes. Both are a quantification of the undecided and a winnowing of possibility, the constriction of the future by means of what has been consumed in the past. Above all, both will be permanent features of capital, slowly accumulating consequences of quick fixes made long-term plan, until the structure that demands them will be undone, by bodies and in time. As that happens, we’ll have to figure out anew what we even mean by body and time: how they work for us, and how to endure, together and without shame, when they refuse to, when sugar gathers around us like snow in summer.
