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129 Conclusion Diabetes and Its Discontents Nearly eight years ­after I first began research for this book, I sat uncomfortably in another room with institutional floors, balancing a bound medical registeronmylap.Aroundme,patientsheldhandkerchiefsorsurgicalmasks over their mouths and leaned against the wall or into plastic chairs. A community health worker sat nearby with a new patient, asking him how many­people slept ­under the same roof in his home and carefully recording his answers . She would need them to initiate contact investigation for tuberculosis , an infectious disease that now kills more ­ people than HIV and malaria combined. At public-­sector clinics like this one in Kampala, Uganda, newly diagnosed tuberculosis patients are recorded in paper registers. They are tested for HIV, initiated on treatment for tuberculosis, and then followed on paper for at least six months of pills and follow-up tests. Despite this, a quarter of ­these Ugandan patients ­ will experience treatment failure. Although tuberculosis is curable, 16 ­percent ­will be dead within the year. I was scanning the register for a key piece of information about each patient that might help identify which among them ­ were most likely to experience treatment failure or death as a result of tuberculosis: their fasting bloodglucose level. Each time I reached a patient with significantly elevated random or fasting blood glucose suggestive of diabetes, I added a tick in my notebook and tried to find any rec­ord of treatment for diabetes. Only two of the six clinics I had visited that week had metformin on hand, though. Even when patients are initiated on treatment for diabetes, many do not continue­because essential medicines for diabetes are not consistently available. The face of global diabetes is changing dramatically. An astounding 80 ­percent of diabetes cases now occur in low-­and middle-­income countries (Critchley et al. 2017). Low-­ income countries like Uganda face rising rates of type 2 diabetes, even as their health systems remain focused on battling epidemics of microbial diseases like tuberculosis and HIV/AIDS. Among rapidly developing middle-­ income countries, China and India alone are home to 110 million and 69 million diabetes patients, respectively. Much as the social epidemiology of type 2 diabetes shifted in the United States from 130 Conclusion high-­ income to low-­ income populations, its geopo­ liti­ cal epidemiology is shifting fast. By 2015, the United States had dropped to forty-­ second place in International Diabetes Federation diabetes prevalence rankings. In its global travels beyond high-­ income nations, diabetes carries some familiar baggage: the burden of stigma, and the perennial challenge of managing a chronic disease when face-­to-­face time with skilled health care providers is a precious commodity. This baggage is transformed by its new contexts, though. In Uganda, for example, fat stigma is rare; fatness is socially valued and strongly associated with health, strength, and beauty. The weight loss associated with diabetes progression is more likely to have negative social consequences in a setting where changes to body mass are associated with HIV. as nikolas ­rose has written in his critique of its overuse and under-­ theorization, “The term medicalization might be the starting point of an analy­sis, a sign of a need for an analy­sis, but it should not be the conclusion of an analy­sis” (2007b: 701). In the preceding pages, I began from the observation that pro­ cesses associated with (bio)medicalization are underway in Japan as in the United States. As the very nature of well-­ being is re­ oriented around biomedicine, both the pathways to and practices of biomedical care become more diverse and more complex. Providers’ recommendations become socially “subjective, collaborative, and highly uncertain” (Spencer 2018: 5). Biomedicalization does not flatten out differences so much as it proliferates them. As the biomedical paradigm has become central to lay systems of meaning, the language and ideas of biomedicine are imbued with cultural meanings (Rose 2007a). In this way, medicine can shape and reor­ga­nize cultural meanings on a ­ grand scale. But the reverse also occurs: the cultural meanings that arise from lay systems shape the patient-­provider encounters that lie at the heart of the practice of medicine. ­ These meetings of lay and medical systems of meaning are sense-­making events in which patients and providers practice culture, and biomedicines and lay cultures co-­produce one another. In the preceding chapters, I considered how and why evidence-­ based practice varies. The providers I described all acted in the best interests of their patients, on the...


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