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VVVVVVVVVVV 21 1 The Chronicity of Life, the Acuteness of Diagnosis CAROLYN SMITH-MOR R IS The biotechnological marketplace shapes much of the discourse on the chronic–acute dichotomy, and ultimately has a significant effect on the foci of medical anthropologists. By distinguishing a condition that is curable and therefore acute (as in broken bones and many bacterial infections) from disease that is incurable and therefore chronic (as in heart disease and diabetes), we leave in place biomedicine’s self-referential system of disease classification (Taussig 1980). Any unquestioned use of this system has the potential of colonizing the lifeworlds of our informants and ignoring (or missing) the lifelong balance of health that they maintain. If, as I will discuss, chronicity is no longer defined by the natural course of disease (e.g., the “slow killers”) but by the availability of biotechnical strategies to address them, then the chronicity of an illness experience is not a medical fact but a technological, political, and economic one. In the contemporary global economy and diaspora, where some infectious diseases produce lifelong cycles of suffering, where the mortal effects of previously deadly disease are averted through new treatments, and where longer lives give rise to new forms of “wear and tear” on the human organism—in short, where chronic suffering is increasingly mundane and invisible—the hegemonic force of the chronic designation loses much of its power. To explore these forces, I turn to a condition for which the lived experience tends to differ markedly from what biomedical tests might reveal: diabetes. The human experience of disease is driven by symptom and experience, and these are both culturally influenced. Lifelong, culturally influenced characteristics of susceptibility, identity, and constitution have little place in the temporal diagnostic categories of biomedicine’s chronic diseases like diabetes. Using ethnographic work among Gila River Indian Community Pima (Akimel O’odham) Indians, spanning two projects over ten years, I propose a view onto the chronicity of life and the acuteness of medical diagnoses that link the pre-, mid-, 22 CAROLYN SMITH-MORRIS and post-disease (i.e., lifelong) states, and offer a more holistic, defragmented approach to health. The Temporality of Biomedicine The chronic–acute dichotomy is fundamentally a temporal marker. Consistent with its Greek etymological roots, the chronic condition is one “marked by long duration or frequent recurrence; not acute” (Webster’s Online Dictionary ). But time is not a neutral concept within biomedicine; it is instead a very powerful factor that is used in the diagnosis, treatment, and labeling of illness (Foucault 1973; Frankenberg 1986, 1995). Time was one of the many conceptual transformations of the eighteenth century. For diagnosticians, time became the unifying structure in predictable, “reproducible” disease processes, as Foucault wrote: “[T]ime was not an unforeseen element that might conceal, and which must be dominated by anticipatory knowledge, but a dimension to be integrated, since it introduces the elements of the series into its own course as so many degrees of certainty. Through the introduction of probabilistic thought, medicine entirely renewed the perceptual values of its domain” (Foucault 1973: 97). Time not only acquired greater precision and importance in the industrializing world, but moved into the authoritative domain of the physician. In using time to establish a diagnosis, the physician imbued his estimates and prognostications with “so many degrees of certainty.” Medical temporalities would be especially influential for diagnosis in the old of age, whose time is assumed to be short and properly devoted to preparation for death (Sankar 1984), or for those who face a life-threatening or disabling condition (Good and Delvecchio Good 1994; Mattingly 1998). “Time is precious, it is short, not to be wasted, experienced with impatience” (Good 1994: 126). Diagnosis of disease essentially robs a person of “their time” (Gordon 1990: 288–289), so health education to reduce severe morbidity and mortality attempts to reduce the time between onset of symptoms and presentation for care. Within this authoritative scheme, diagnostic activities determine the form of disease and its label. Temporal factors in diagnosing, such as the length of symptoms or the number of episodes in a given time frame, help diagnosticians decipher fundamental patterns in the disease process. As Foucault’s analysis suggested, the physician’s concern is to know the “natural course of disease”; s/he must interrupt the natural course in order to treat the patient (Foucault 1972, 1973). In this paradigm, biomedical diagnosis is actually clouded...

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