A Summary and Kairology of the Rhetoric of Diabetes Management

Image Credit: http://www.digjamaica.com/diabetes

The title of this blog is “The Rise of the Diabetic Cyborg,” and my academic research deals primarily with diabetes and rhetoric, yet I’ve never devoted an entire post to the topic. The disorder has shown up throughout many of my posts when I try to apply theory to my academic interests. It’s high time, though, that I take a look at the ways in which diabetes is discussed in the field of rhetoric. This post returns to my summarizing and questioning ways of old. Here, I will discuss four articles that look at the rhetoric of diabetes. The purpose of this post is to review some of the ways in which the field of rhetoric has discussed diabetes over the past several years, namely, how it has shifted in its concepts of agency. I review “In Search of Patient Agency in the Rhetoric of Diabetes Care,” by Mary Specker Stone; “Diabetes and Literacy: Negotiating Control Through Artifacts of Medicalization,” by David S. Martins; “Troubled Interventions: Public Policy, Vectors of Disease, and the Rhetoric of Diabetes Management,” by Jeffrey A. Bennett, and “Resisting the Rhetoric of Diabetes Management,” also by Bennett.

Image Credit: http://www.movemoretoday.com/resist-not/

Agents of Responsibility: The Rhetoric of Diabetes Management

Much of the rhetorical scholarship on diabetes has focused on the rhetoric of diabetes management and its effects on the individual with diabetes. Mary Specker Stone, writing in the late 1990s—her article was published in Technical Communication Quarterly in 1997—uses rhetorical theory to examine whether or not a shift to managed care for patients with diabetes grants them true agency or simply seeks to control them under a guise. Managed care, in this case, means putting patients in charge of their own personal care, placing the responsibility for their health with them. She finds that managed care advocates and organizations do attempt to grant more agency to people with diabetes but “in the cumbersome rhetorical manner that their biomedical discourse community requires of them” (215). This discourse community is founded on the biomedical model, which requires physicians to objectify patients, making them part of the overall diagnosis/treatment situation, a variable (214). Because of this objectification, about which is written in their own journals, the shift to a more humanistic approach that values the patient as another caregiver (as well as receiver) is strained. Also participating in the discussion about managed care—albeit, 15 years later—Jeffrey A. Bennett argues against the managed care approach. Bennett believes that “‘management’ often trivializes and derails the lives of the people it seeks to aid” because, he argues, “discourses of discipline deflect attention away from a cure and render the everyday complications of diabetes mute. Blame is projected onto the diabetic body and the individual alone is responsible for eradicating disease” (“Resisting the Rhetoric of Diabetes Management” 3). This idea took me by surprise when I initially read it. The thought that the greater agency, as Stone advocates for, seemingly granted in the rhetoric of managed care, is turned against people with diabetes came close to a head-exploding moment for me. It makes sense, though. Put people in charge of managing their own disorders, which might give them more control over their own lives, but it also leaves them with no one else to blame if things don’t go well. It turns the victim of the disease into its henchman accomplice as well.

David S. Martins, who chronicles his experience with the California DMV as a diabetic, finds similar methods of individual blame placed on the diabetic body. Upon receiving a driver’s license suspension order for failing to respond to a questionnaire about his diabetes, Martins’ social role as a diabetic is transformed into “patient-as-defendant” who must “acknowledge the authority of medical and bureaucratic institutions” (121). People with diabetes are forced to internalize their disease’s management, take charge of their own care, or be subject to institutional controls, a society of diabetic discipline: “The literacy and rhetorical practices enabling this kind of social control requires the textualization of the body, and in this case, we see a system regulating not simply a standard kind of body but a standard political subject that is, or should appear to be, compliant” (126). Are you thinking what I’m thinking? Foucault! Discipline and Punish lays out this system of institutional discipline. Bennett thinks a systemic approach to diabetes care is the answer to the rhetoric of diabetes management. He analyzes a system in New York City, which has recently attempted to create a diabetic registry to combat the “epidemic” of diabetes. Bennett advocates for this paradigmatic shift. The epidemic metaphor “may help shift conceptions of diabetes from being a privately managed disease to a condition that is collectively and socially engendered” (“Troubled Interventions” 17). While scholars like Stone see the rhetoric of management as granting agency to diabetics, others like Bennett and Martins see the “added” agency as a way to deflect blame onto those who suffer from the disease and institute more bureaucratic control over them.

The Universal Symbol for Diabetes
Image Credit: http://wpcontent.answcdn.com/wikipedia/commons/thumb/4/43/Blue_circle_for_diabetes.svg/230px-Blue_circle_for_diabetes.svg.png – blue circle

A Kairology of Diabetes Management

The differences in opinion between Stone’s advocacy for agency and the potential negative effect of the rhetoric of management pointed out by Bennett and alluded to by Martins is, I think, one of kairology and temporality. I discuss kairology in my Canguilhem reflection, but here is what I say about it:

In the fantastic book Health and the Rhetoric of Medicine, Judy Z. Segal explains a concept called kairology. This concept is taken from kairos, “the principle of contingency or fitness-to-situation” (17). Kairology studies the historical “shifts understood as responses to changes in situation” (17). When a shift occurs, it is precipitated by some kind of contextually specific exigency.

Stone’s article was published in 1997, only four years after the New England Journal of Medicine published “The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus” from The Diabetes Control and Complications Trial Research Group, also known as the DCCT. This trial followed people with diabetes for years and found that intensive treatment of the disease led to drastically reduced risk for long-term complications (retinopathy, neuropathy, nephropathy, etc.). This article revolutionized the way physicians treated people with diabetes. Following its publications, there was a movement to push intensive treatment, which can only be successful if the patient plays an integral role in the care plan. It requires testing blood glucose several more times per day than previous—sometimes up to 10—and delivering corrective insulin shots in between meals—opposed to only before meals or sometimes even fewer. It is from this “contextually specific exigency”—the publication of the DCCT’s findings—that the rhetoric of management arose, and it is the context surrounding Stone’s article. Within Stone’s context of use, people with diabetes needed agency and recent scientific developments supported that agency. It was the right argument to make at the time.

Since 1997, though, science has shifted to allow for greater partnership between patients and physicians, which Stone certainly anticipated. It is within this new context that Bennett and Martins offer their arguments. Bennett and Martins are writing nearly 15 years later, after another important “contextually specific exigency” occurred. In 2001, the Institute of Medicine declared that patient-centered care would become one of its six focal points in improving care (Crossing the Quality Chasm 6). From patient-centered care, we get patient-centered communication, a style of communication directly opposed to the biomedical communication style, which Stone points to as the hindrance in creating agency for people with diabetes. Bennett and Martins are writing about a healthcare system that is fundamentally different from the one Stone addresses. The current model has accepted the DCCT’s findings as gospel, employing the rhetoric of management in every new diabetes education class. Bennett and Martins, though, seem to think this model of self-management has gone too far.

It’s a fascinating rhetorical history to trace, and I don’t think we can determine if Bennett’s argument is indeed kairotic (fit to the situation). It appears as though it might be, but to trace kairology, we really do need the 20/20 hindsight of reflecting on the past.

Works Cited

Bennett, Jeffrey A. “Resisting the Rhetoric Of Diabetes ‘Management’.” Conference Papers — National Communication Association (2009): 1. Communication & Mass Media Complete. Web. EBSCO. 06 August 2013.

—. “Troubled Interventions: Public Policy, Vectors of Disease, and the Rhetoric of Diabetes Management.” Journal of Medical Humanities 34.1 (2013): 15-32. Web. EBSCO. 19 July 3013.

Diabetes Control and Complications Group. “The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus: The Diabetes Control and Complications Trial Research Group.” The New England Journal of Medicine 329.14 (30 September 1993): 977-986. NEJM. Web.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21^st Century. National Academies Press: Washington, D.C., 2001.

Martins, David S. “Diabetes and Literacy: Negotiating Control Through Artifacts of Medicalization.” Journal of Medical Humanities 30 (2009): 115-130. Web. EBSCO. 31 May 2013.

Segal, Judy. Health and the Rhetoric of Medicine. Carbondale: Southern Illinois Press, 2005. Print.

Stone, Mary Specker. “In Search of Patient Agency in the Rhetoric of Diabetes Care.” Technical Communication Quarterly 6.2 (Spring 1997): 201-217. Web. EBSCO. 25 July 2013.