- Bittersweet: Diabetes, Insulin, and Transformation of Illness
Chris Feudtner is both a physician and a historian, and this book interweaves a historical account of how patients and physicians experienced and understood (type 1) diabetes care (both before and after the introduction of insulin in 1922) with his argument that advances in medical treatment typically, as in the case of diabetes, transmute rather than conquer disease, transforming the experience of illness rather than eliminating it.
Feudtner's primary data source is the extensive written correspondence between and Elliott Joslin and other physicians of the Joslin Diabetes Center and their patients. (The Joslin Diabetes Center is based in Boston, where it was founded in 1898 and where it is today affiliated with Harvard Medical School; Joslin has affiliates across the country.) These letters span Joslin's career from his first diabetic patient in 1898 to its end in 1962. This period saw astonishing changes in the treatment of diabetes, most importantly the introduction of insulin in 1922, and as a result remarkable advances in the survival of diabetic patients.
In this patient-centered account, the new tasks and responsibilities placed on patients and their families with the introduction of insulin therapy are clear, both in the letters and in a remarkable series of cartoons drawn by one of Joslin's patients. What may impress the reader more is how much continuity there was in Joslin's general therapeutic approach. Both before and after the introduction of insulin, he pushed patients hard to follow detailed dietary and lifestyle instructions. Before insulin, this was seen as the price for a few months' or (rarely) years' additional survival. After insulin, it was the requirement for good health without complications. Throughout, the issue of how far patients could or would go to follow medical advice remained central.
Bittersweet will be of use to anyone who wants to get a perspective on the ongoing negotiations between patients and physicians in the care of chronic diseases, or to evaluate Feudtner's argument that medical advances continually transmute disease processes in ways that create new problems to replace the old. It very sensibly underlines the need for modesty in medicine. If those involved in the care of diabetes and other chronic diseases—either as patients or as care providers—are better able to recognize that diabetes still resists control, that despite the most aggressive management it will often shorten or limit the lives of patients, and that sometimes no one is responsible for this tragic reality, Feudtner will have achieved his aim.
Because it is based on records from an elite, tertiary medical care center during a period when American medical care was primarily on a fee-for-service basis, Feudtner's [End Page 652] account only occasionally reflects the extra burdens posed by economic disadvantage. Bittersweet includes letters from patients seeking guidance on just how important a proposed visit, hospitalization, or procedure may be, and putting off seeking care until finances permit, and physicians seeking charity care for patients they know are in need—but poor or illiterate patients do not appear in these pages. For those engaged in health care for the poor and underserved, the need for history that brings to life the experiences of disadvantaged patients persists.
Jessica Robbins is a public health epidemiologist in the Philadelphia Department of Public Health (PDPH), Division of Ambulatory Services. She can be reached at the PDPH, AHS 500 South Broad St., Philadelphia, PA 19146; (215) 685-6426; Jessica.firstname.lastname@example.org.