Social Science & Medicine 58 (2004) 2371–2382

ARTICLE IN PRESS

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Controlling diabetes, controlling diabetics: moral language inthe management of diabetes type 2

Dorothy Brooma,*, Andrea Whittakerb

aNational Centre for Epidemiology and Population Health, The Australian National University, Canberra ACT 0200, AustraliabThe Key Centre for Women’s Health in Society and The Melbourne Institute of Asian Languages and Societies, University of Melbourne,

Victoria 3100, Australia

Abstract

Contemporary management of diabetes places heavy emphasis on control, particularly control of blood sugars and of

food consumption. Interviews with people living with diabetes type 2 show how identity and social relationships are

negotiated through what is often a contradictory language of control, surveillance, discipline and responsibility. People

frequently discuss diabetes-related behaviour in terms that position themselves or others as disobedient children, or as

wicked or foolish adults. These references occur alongside appraisals of the physical and social complexity of

‘‘compliance’’ with diabetic regimes and in some instances the difficulty of achieving effective control over blood sugar

levels. Efforts to protect themselves from the stigmatising potential of diabetes may inadvertently undermine the agency

of people who are already coping with a demanding discipline and a potentially disabling or life-threatening disease.

r 2003 Elsevier Ltd. All rights reserved.

Keywords: Type 2 diabetes; Disease management; Moral responsibility; Social stigma; Lay explanatory models

Introduction

Diabetes mellitus is the seventh leading cause of death

in Australia (roughly similar to the USA, the UK and

many developed societies). Its estimated prevalence is

4%, with much higher rates among certain subpopula-

tions, including older people, Indigenous Australians,

ethnic Chinese, and Pacific Islanders (Colagiuri, Cola-

giuri, & Ward, 1998).1 Despite extensive health promo-

tion campaigns, the prevalence of diabetes continues to

rise so rapidly that it is generally labelled an ‘‘epidemic’’.

Thus, the physical and social challenges of diabetes

affect substantial and increasing numbers of the adult

ing author. Tel.: +61-2-6125-5546; fax: +61-2-

ess: Dorothy.Broom@anu.edu.au (D. Broom).

90% of diabetes is Type 2 or ‘adult onset’.

formerly called ‘non-insulin dependent diabetes

IDDM), some people with diabetes Type 2

e front matter r 2003 Elsevier Ltd. All rights reserve

cscimed.2003.09.002

population, and because it is a chronic condition, the

challenges must be faced daily for life.

Contemporary management of diabetes places heavy

emphasis on individual responsibility for diabetes

control, particularly control of blood sugars and of food

consumption. In this paper, we explore how people with

diabetes describe the everyday lived experience of

managing the disease. We concentrate on the language

people use to shape and account for the disruption

diabetes causes in their lives. Identity and social

relationships are negotiated through what is often a

contradictory language of control, surveillance, disci-

pline, and responsibility.

We analyse people’s accounts of their diabetes in a

number of ways. At one level, we focus on the discourses

used, the themes, metaphors, and imagery people use to

describe diabetes and its management. We also analyse

these insofar as they form parts of narratives of diabetes

causality and management. A number of studies note

the importance of language in the management of the

disruption of chronic illness and the integration of

positive meanings into people’s identities. For example,

d.

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–23822372

Becker describes how people with chronic conditions use

metaphors to integrate ‘‘out-of-the-ordinary life experi-

ences into identity. In using metaphor, people work

simultaneously on changes in their identities and on

changes in their livesy Metaphor thus serves as a

mediator for change, enabling individuals to re-establish

a sense of connection with the social order, while

obscuring social paradoxes and unresolvable dilemmas’’

(Becker, 1997, pp. 197–198). Similarly, Riessman has

noted the ‘‘strategic uses’’ of forms of narrative for the

presentation of self and illness during research inter-

views. She shows how a divorced, working class man

with multiple sclerosis constructs a definition of his

situation and accomplishes a positive masculine identity

despite his failed marriage and his disability (Riessman,

1990). In this paper, we argue that diabetes often

threatens to spoil or discredit the identity, and that

people counter this threat in various ways, through what

they say and do. As speech acts, people’s explanations of

diabetes constitute presentations of the self and have

performative qualities, constituting persuasions or argu-

ments. In this case, we suggest that the language we

describe has a moral dimension as a form of ‘‘self-

making’’ (Battaglia, 1995), both acknowledging and

distancing the speaker from the potentially discredited

identity of diabetes.2 We are particularly interested in

how people’s narratives about their diabetes may be ‘‘a

dialogue of moral codes about how one ought to live or

who one ought to become’’ (Mattingly, 1998, p. 118)

and a means to experiment with a variety of self-

understandings.

After describing the research methods, the first part of

this paper outlines several ways diabetes imparts a

spoiled identity. Participants describe a culture of

surveillance and monitoring in which the control of

blood sugar levels through diet, exercise, and medication

becomes a primary goal. Although diabetes is often

represented as a ‘‘lifestyle’’ disease for which people may

be blamed, lay explanatory notions propose a wider

causality which can normalise the condition and

minimise the moral implications of the illness. The next

part of the paper concentrates upon the ways in which

people talk about diabetes management, constructing

self-reflexive accounts that present their identities in

positive terms. These include explicit moral terms, such

as being ‘‘good’’ and ‘‘bad’’, parodies of adults scolding

children, or narratives of guilt and salvation. A common

theme in such accounts is the struggle between strict

compliance to a diabetic regime and the assertion of

2We are aware of controversy surrounding the use of the

term ‘diabetic’. Some people object to the implicit reduction of

the person to their disease as potentially discrediting in itself,

while others regard it as an accurate and candid description.

For verbal economy, we occasionally use the word, respecting

that it carries undesirable connotations to some people.

individual agency. The multiple meanings of control

form a central part of the moral discourse surrounding

diabetes and people’s efforts to claim some autonomy in

their disease management.

Method

Detailed interviews were conducted with 119 adult

diabetics (sometimes with family members present) and

56 service providers (including general practitioners)

located in three locations in a south-eastern Australian

state (two rural towns and one urban area). The

unstructured interviews invited participants to tell the

story of their diabetes from diagnosis to the present day,

concentrating particularly on how they felt their

diabetes affected their daily lives, what difference it

made. In addition, we attended one meeting of a large

clinic-based diabetes support group and conducted a

focus group discussion with a meeting of general

practitioners interested in improving their expertise in

diabetes management. Interviews were tape recorded

and transcribed verbatim, and the transcripts entered

into The Ethnograph program for the analysis of text-

based data where they were coded thematically. The

findings reported here are derived from the interviews

with ‘‘consumers’’. Because the interviews were not

tightly structured, and because most social or demo-

graphic categories in the sample would contain com-

paratively few people, we have not conducted any

comparative analysis by class, ethnicity, or age.3

The people we interviewed are generally experienced

at dealing with diabetes; on average (median), they had

received their diagnosis 10 or more years ago, although a

few were diagnosed quite recently. Three of the

participants have Diabetes Type 1, but the remainder

have Diabetes Type 2 (the focus of the study). Their ages

range from 20 to 90 (mean, 64). Slightly more males

(52%) than females participated (see Table 1). They

included two Indigenous people who were peer educa-

tors working with an Aboriginal Health Worker. Less

than 10% of participants came from non-English-

speaking backgrounds, and all but two could speak

English reasonably well. As would be expected in such a

sample, proportionally more of the women than the men

were widowed. In other respects, the sexes were

generally demographically similar except that nine

women (but no men) identified their occupation as

‘‘home duties’’. Slightly under 1/3 of the sample defined

themselves as ‘‘retired’’ (equal proportions of men and

women), while those still in paid work were scattered

over a variety of blue collar, white collar, and

professional occupations.

3Future publications will address gender comparisons and

data from service providers.

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Table 1

Sample description: marital status by gender

Marital status Total sample Females Males

Number Percent Number Percent Number Percent

Married 91 76.5 46 76.7 45 76.3

Single 10 8.4 4 6.6 6 10.2

Divorced/separated 4 3.4 1 1.7 3 5.1

Widowed 14 11.8 9 15.0 5 8.5

Total 119 100.1 60 100.0 59 100.1

D. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–2382 2373

The ‘spoiled identity’ of diabetes

The moral dimensions of health and illness have been

extensively canvassed by many social scientists. As

Sontag observes, disorders have always been scaled

according to the degree to which people are felt to be

morally responsible for their illness (Sontag, 1978).

Health is often represented ‘‘as a virtue, as a matter of

right conduct, and illness as a sign of sinfulness and a

warning to the individual’’ (Williams, 1993, p. 92). The

functionalist construction of illness as a form of

deviance requiring social control shows that ‘‘the sick

role’’ is only provisionally legitimate, contingent on

adherence to specific normative requirements (Parsons,

1951). If these norms (including eventual recovery) are

violated, a sick individual’s personal worthiness can be

called into question (Estroff, 1993; Kassenbaum &

Bauman, 1965; Posner, 1977).

The spoiled identity associated with diabetes has a

number of dimensions. Firstly, diabetes is frequently

represented as a self-induced ‘‘lifestyle’’ condition, a

disease of excess suffered by those who have over-

indulged. In lay discourses, it is commonly attributed to

people who lack ‘‘self-control’’, who eat to excess and

are overweight. This view is reinforced by health

promotion, which emphasises that one should avoid

diabetes through a ‘‘sensible’’ diet and exercise. People

with diabetes are thus frequently blamed for their

disease, for ‘‘not looking after themselves’’ and failing

to take proper responsibility for their health.

Further, as with any illness, the sufferer deals not only

with the disruption of their lives and the imperative to

change their lifestyle, but also confronts a society that

often views them as different, less than ‘‘normal’’

(Goffman, 1963). Although diabetes is not generally

evident to others, people resented their difference being

highlighted in social situations. Brian described being

‘‘treated like a leper’’ on a bus tour which included

several other diabetics. For the convenience of caterers,

the diabetics were all seated at a separate table for meals

and served an extremely limited diet, which Brian

resented bitterly. A number of our respondents said

they wanted to be treated as ‘‘normal’’ and not to ‘‘stand

out in the crowd’’. This was a topic of lively comment in

the support group, but people interviewed alone also

mentioned it. ‘‘You are resentful that everyone else is

not like that, you know’’ (Sam). Similarly, a number of

people also mentioned—and begrudged—needing a

doctor’s certificate to renew their driving license. They

felt they were no more liable to have problems driving

than anyone their age or compared to people who had

other medical conditions that are not subjected to such

medical surveillance and regulation. Some participants

in this study mentioned discrimination, such as pro-

blems getting or keeping jobs because of their diabetes.

While such discrimination may not be legal, several

people were concerned about the effect diabetes might

have on their employment and a few told stories that

they were anxious to keep anonymous for fear of

reprisals.

The management of the condition also brought its

own stigma. For example, those who require insulin

need injections and hence needles. The new insulin pens

look less like a syringe, but they still involve injecting

and its negative social connotations. Several people

volunteered stories of distress and indignation at being

assumed to be drug addicts when they had to inject in a

semi-public location. Furthermore, symptoms of very

low blood sugar (hypoglycaemia) can include confusion,

dizziness, irritability and, in extreme instances, aggres-

sive behaviour or loss of consciousness, so someone

experiencing a ‘‘hypo’’ can be mistaken for being drunk,

and several respondents felt humiliated by these

discrediting experiences. Some people wore a ‘‘Medic

Alert’’ tag to inform others of their disease status, but

the tags would probably only be accessed in an

emergency, so although supplying some reassurance,

they did little to diminish the stigma.

Finally, another aspect of diabetes management with

moral implications is the issue of people’s ability to

‘‘control’’ their blood sugar levels (henceforth BSLs).

Persistently elevated blood sugars increase the prob-

ability of serious long-term complications; however, the

use of the term ‘‘control’’ is not limited to this

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–23822374

apparently technical domain. It also appears frequently

and with numerous other objects of control, including

weight, diet generally, consumption of sweets or fats,

activity levels and exercise, and indeed, control of the

self. That is, diabetics describe themselves, one another,

and their behaviour as having or lacking control, as

being under or out of control.

In the context of contemporary ‘‘healthism’’ (Met-

calfe, 1993), control per se is assumed to confer health

benefits and has become a value in itself, desirable for its

own sake regardless of its apparent impact on health.

These views are intensified in diabetes, where control of

blood sugar levels is explicitly understood as signifying

health and compliance with the therapeutic regimen.

Thus, failures of control imply not only poor health, but

moral failings. The imposition of a rationalist medical

model on disease management often attributes to

diabetics personal responsibility for maintaining accep-

table blood sugar levels through adherence to a regime

of regular professional supervision, self-surveillance,

diet, exercise, and often, medication. Hence, people with

diabetes are vulnerable to being stigmatised by friends,

other diabetics, and health professionals. Our infor-

mants described a culture of surveillance and monitor-

ing. As we describe below, people have a number of

defensive strategies against such monitoring to maintain

an image as someone ‘‘in control’’.

Some of the stigmatising potential of diabetes may

have diminished in recent years with media campaigns

and increasing public awareness. A number of partici-

pants who had had diabetes for some years (or had an

older friend or relative with diabetes) volunteered that in

times past, there was considerable shame associated with

it. They said that a decade or more ago, diabetes was

associated with inevitable physical disabilities, amputa-

tions, blindness, and early death. While the spectre of

these complications still looms large, they are no longer

considered unavoidable. Ada is very active in her local

Diabetes Association. She recalled: ‘‘Our treasurer-

ysaid that 25 years ago when they first started the

branch, she’d walk into the bank and she’d say ‘Can I

have the bank statement for the Diabetes Association’,

and she said people would just walk away from her like

it wasyleprosy or something like that’’. Several had

similar stories and felt that elements of this generalised

dread of diabetes persists into the present. Ada’s

reiteration of Brian’s comparison with leprosy signals

the persistent socially (if not physically) disfiguring

potential of diabetes.

Lay explanatory models of diabetes

It is possible to discern a number of lay explanatory

models of the genesis of diabetes which incorporate

people’s experiences and understandings of their illness

into existing cultural models and symbolic meaning

systems (Kleinman, 1978). As research on breast cancer

among southern black women demonstrates, an indi-

genous explanatory framework may be informed by

occasionally contradictory biomedical and popular

notions where metaphors work to adapt personal illness

experience to pre-existing explanatory frameworks

(Mathews, Lannin, & Mitchell, 1994). Likewise, in our

work on diabetes, it is possible to discern metaphors and

imagery which draw upon both biomedical explanations

of the causes of diabetes as well as more popular notions

of the body and its workings. Not all the multiple

explanations were congruent. People can apply a

number of differing explanations simultaneously with-

out being troubled by the apparent contradictions.

People drew little distinction in their narratives

between onset and management of diabetes: between

causality of disease and risk of complications. Usually,

diabetes begins as a condition defined by elevated blood

sugar levels rather than symptoms, so it is not surprising

that diagnosis and management are elided: getting and

having diabetes are very similar experientially.

‘‘Lifestyle’’

Many people living with diabetes subscribed to the

‘‘lifestyle’’ model of the aetiology of diabetes, a view that

might be reinforced by the media and contact with

medical professionals. Surprisingly, a number used quite

unflattering imagery to describe the reasons for their

diabetes. For example, Sam explained: ‘‘I think diabetes

is just fat people eating too much fat’’. When she was

asked what had caused her diabetes, a teacher said,

‘‘being overweight and eating far too many sweet

things’’. ‘‘Mine is from obesity,’’ explained Charles,

reiterating verbatim a description his wife had just

supplied. ‘‘I’d say inactivity, most probably overindul-

gence’’.

While such descriptions might be unattractive, they

also often entail a story of redemption, of having

corrected one’s past wrongs. For example, talking about

the way he used to eat the fat on meat, Vincent (age 51)

said, ‘‘But there’s no way in the world I’m going to have

it [now], I cut it all off. If I had have done that years ago,

I mightn’t be diabetic’’. Vincent compares his past to his

reformed (and healthier) present. In doing so, he

presents the listener with a tale of self-improvement, a

positive view of himself now as knowledgeable and

managing his diabetes ‘‘well’’ and ‘‘correctly’’.

One expressive device was the typification of the

idealised candidate for disease that often figures in lay

constructions of risk (Davison, Davey Smith, & Frankel,

1991; Davison, Frankel, & Davey Smith, 1992). With

what is perhaps an accidental play on words, Ulrich

described the model of a ‘‘dead ringer’’ (an Australian

expression for someone who looks exactly like someone

ARTICLE IN PRESS

4His metaphor is similar to that described by Emily Martin

(Martin, 1994).

D. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–2382 2375

else.) ‘‘Well I reckon that if you’re over 50, overweight,

and have hypertension, you’re a dead ringer for it! It’s

just the classic symptoms. And if I had any sense earlier

on, I would’ve tried to lose weight, I would’ve made a

bigger effort’’ (Ulrich). This 60-year-old sales represen-

tative explicitly framed his duty of control retrospec-

tively, an outlook he shared with several other

respondents. In shifting from a generalised description

using the second person pronoun ‘‘you’’ and third

person ‘‘it’’ to describe the symptoms of diabetes, to the

first person ‘‘I’’, he draws parallels between the general

characteristics and his personal experience. His exhorta-

tion at the end moves his account of the ‘‘dead ringer’’

into an explicit morality tale, a warning to the listener,

to learn from his experience and change their own risky

lifestyle.

Extenuating circumstances

But as Davison and colleagues note, the notion of the

‘‘dead ringer’’ also implies its opposite—people who do

not develop diabetes despite their lifestyle and risk

factors (Davison et al., 1991; Davison et al., 1992). Such

images imply that explanations of the causality of

diabetes as indulgence are incomplete and confirm

suspicions that diabetes is due to ‘‘something else’’.

For example, Eunice described her diabetes as due to

‘‘just something that fails in your body’’. Her husband

went on to elaborate that it must have been due to

‘‘something failing in your [Eunice’s] system. The thing

that makes it [insulin] inside’’ because he can ‘‘eat

chocolate, lots of chocolates and sweets, and it

never affected me’’. In this instance, the fact that he

can eat sweet foods without noticeable ill-effects is

evidence that Eunice’s diabetes results from something

other than her eating. Likewise, Luther, a waiter,

explained diabetes in terms of ‘‘different metabolisms’’,

saying ‘‘sometimes the body just doesn’t produce its

own insulin’’.

Such models of diabetes serve to minimise the moral

implications of illness. People named ageing, heredity,

and viral infections as implicated in the genesis of their

particular condition—factors over which they cannot be

expected to exercise control. For example, Wanda noted

her family history in explaining her diabetes. ‘‘I mean,

you know overweight can be, you know, too much

eating, and soyyou’re eating all the wrong foods. But it

can also be genetic and I come from a big family. I

meanymy mum must have been, I reckon she would

have been 20 odd stone’’. Sam, whose twin brother and

grandfather were also diabetic, used the word ‘‘inevi-

table’’. Fred, a fit, active 70-year-old retired butcher,

explained ‘‘that the pancreas breaking down seems to be

part and parcel of a lot of other things that break down

as you get older’’. A number of other participants had

similar ideas: ‘‘The doctor said it was age-onset

diabetes’’, as if the label contained its own aetiological

explanation.

Biomedical legitimation

As in Fred’s example above, people often referred to

an expert (whether institutional such as Diabetes

Australia, or individual, such as a specialist, diabetes

educator, or GP) as the source of a mitigating

explanation, to reinforce their claim. A retired nurse

(whose diabetes was one of a number of personal and

health problems) cited a generalised authority: ‘‘yThey

feel that all those stressful incidents have got an impact

on diabetes developing’’. A widower in his late 60 s

reported, ‘‘I asked the doctor, he said it could have been

shock’’. A retired mechanic quoted both his specialist

and the diabetes educator to verify his belief that the

source of his diabetes was ‘‘heredity’’ (Neville).

Common representations of causality invoke biome-

dical concepts such as viruses and infections in the onset

of their diabetes. One person described the cause as

‘‘Russian flu’’, and another had had hepatitis; but most

who thought there was such a trigger did not specify a

particular infection or period of sickness they had

experienced and referred to an unnamed virus as the

culprit. One woman wondered whether it might be ‘‘a bit

of a viral thing that you might catch that affects the

pancreas’’. A variant of this appeal to specific pathogens

or external triggers included a pharmacist’s explanation

that exposure to synthetics and pollution were con-

tributing to both the increasing prevalence of diabetes

and to people’s difficulties managing their blood sugars.

Tom evoked a military image of the immune system as

‘‘how our body treats everything as an invasion, and this

is what is happening where they are chewing up their

own pancreasysomehow rejecting that or treating it as

the enemy’’.4

Stress

A dominant model of causality involved the effects of

stress upon the body—a very common theme in lay

explanatory models of another chronic condition,

coronary heart disease (Whittaker, 2002) and other

contemporary health problems (Hunt, Browner, &

Jordan, 1990). The stress motif draws attention to lay

understandings of the influences of the psycho-social

context on the physical body, the body as ‘‘sociocentric’’

(Scheper-Hughes & Lock, 1987). Stress is described as

an external force over which people have little or no

control, which ‘‘brings on’’ diabetes, or creates the right

conditions for it to ‘‘get going’’. ‘‘Stress’’ is used to gloss

a range of different life experiences. For example, a man

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–23822376

who has had numerous health problems and surgical

procedures repeated several times that his diabetes had

been caused by ‘‘the trauma’’ of the operations. Most

people who mentioned stress, however, used the term in

reference to personal life events and also to the daily

demands of working and living. Irene, whose adult

children had moved away, thought that the stress of

their leaving might have something to do with her

diabetes. A retired truck driver and his wife wondered

whether a motor-vehicle accident might have ‘‘brought

it on’’.

Vincent’s narrative provides a typical example of how

people’s descriptions of their diabetes are often woven

into wider narratives about their social relationships and

stressful life events. Vincent describes the death of his

father and his own divorce as implicated in the genesis of

his disease.

I think the thing that made me diabetic, my father

died two years before I became diabetic and he was

down here on holidays, got sick, I took him to the

hospital and he died three days lateryA couple of

months after that I got married, 12 months after I got

married, my marriage broke up and that, my wife put

me through a lot of emotional blackmail and things

like that, you know so I think all that within two

years, that was terrible and I think that’s what really

got the diabetes going.

His account makes explicit links between events two

years before onset of his diabetes, re-framing his disease

in terms of his social relationships in a narrative that

collapses time. This illustrates the multiple meanings a

disease carries in a person’s life and identity, as illness is

‘‘inseparable from and responsive to those internal and

external meanings and relationships’’ (Stein, 1985).

Likewise, Ivan told a story of a sequence of major life

events.

The day after my daughter got married, my wife died

y I do blame that as the fact that I ended up with

diabetesy There was no sign of anything like that, I

had blood pressure and normal things at my age, no

heart complaints, just the blood pressurey. I do

blame [her] deathy it created the problem with the

diabetesy It just built up and built up and bingo.

These images of an accumulation of burdens finally

overwhelming the body’s capacity to cope appeared in

several accounts. Harry distinguished between causes

and triggers, suggesting that ‘‘most people have the

capacity to be a diabeticyit just needs something to

click it offy.I don’t know whether it’s just, you know,

everybody’s got it and I suppose it’s like cancer, it’s like

something else it just needs something to trigger it off’’.

He thought that both his own diabetes and his father’s

had been activated by injuries. In such accounts,

diabetes is a latent potential condition, a metaphoric

bomb requiring some factor to ‘‘trigger’’ it.

Karen (whose adult son was also diabetic) confidently

stated that diabetes is caused by stress and proposed a

mechanism. ‘‘Stress is tension. If you’re tight, food

cannot work well in your body’’. Hers is a hydraulic

view of the body as tight and constricted rather than

open, relaxed and permeable. In this image of constric-

tion, normal bodily flows are disrupted, including that

of nourishment. Diabetes is thus a condition whereby

food does not ‘‘work well’’ in your body; no reference is

made to the pancreas and its function or to cellular

processes of insulin resistance. Her husband has had a

mental health problem for many years, and also refuses

to eat the food she believes is best for her, so his illness

and family food preparation present significant daily

difficulties which she glosses as ‘‘stress’’. The relation-

ship between stress and diabetes thus reflects the ways in

which people perceive their health within the larger

context of their lives as social beings who work, have

families, and are subject to outside pressures.

Narratives of management

In talking about their condition, people with diabetes

describe an ongoing struggle to manage their disease and

their identities. This often takes the form of commen-

taries on the ambivalences of diabetes management and

the desire to present a positive subjectivity. The

expressive devices people employ and the stories they

tell suggest complementary and contradictory alterna-

tives typical of the ‘‘double bind’’. Such language is a

means through which people point towards different

possible selves and experiment with a variety of self-

understandings (Mattingly, 1998).

The ‘‘contest for control’’

Stein (1985) recognised the ‘‘contest for control’’ as a

theme pervading multiple contexts of meaning in the life

of a person with diabetes. He notes, ‘‘What is from the

physician’s’’ viewpoint a compliance problem (that is, a

struggle for control) is from the diabetic’s a struggle for

self-discipline. In the treatment of diabetes, the goal is

(after Freud) to replace the pancreas with the ego’’

(1985, p. 116). Regardless of what their blood sugar

readings show, a number of participants asserted it was

possible to exert complete control over their BSLs, ‘‘I do

know that it’s in my control to get it right down’’. Here,

Rosa was contrasting her present reliance on medica-

tions with a desire to manage her BSLs through

diet alone, and the implicit self-criticism in her current

failure to do so.

Such statements position the person with diabetes as

an agent capable of exerting positive influence over their

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–2382 2377

BSLs, despite the fact that most people said their BSLs

were higher than recommended, at least occasionally. As

noted earlier, the presentation of the self is a funda-

mental problem for people whose sense of identity has

been disrupted by disease. Narratives of management

tend to depict the person with diabetes in a continual

dialogue with the self. Mattingly describes such ‘‘little

narratives’’ as ‘‘self-conscious in their incompleteness’’

and filled with moral uncertainties (1998, p. 116) defined

by ‘‘(a) a depiction of time as something still open to

future revision, including moral revision; and (b) the

presence of multiple voices which offer different moral

perspectives’’.

For example, in the following narrative, Sam de-

scribes his struggle to manage diabetes in terms of the

constant self-reflexivity imposed by his condition:

You’re in sort of denial and you think, ‘‘oh bugger. It

I’ll have a drink,’’ because you think it’s your right to

drink and your right to, you know, continue the way

you are going without changing. I think even if you

have periods that you do the right thing, you still get

into a period then that you say to yourself, you

know, I’m going to y

immediately elaborating: ‘‘you’re only having yourself

on, you’re not cheating anyone else’’. When he was

asked to clarify what he meant by ‘‘doing the right

thing’’, Sam explained:

Well ‘‘doing the right thing’’ is going against what

you’ve done in your eating habits all your life. And

then someone’s all of a sudden saying to you, you are

going to eat this and you are going to do that and

you can’t have a bit of cake and you can’t do this,

you know.

The prohibitions themselves made him feel as though he

was being treated like a child (‘‘being told’’), so he

reclaimed his adult status by asserting an individual-

rights discourse (‘‘it’s your right to drink’’) and refusing

to adhere to the regimen, but his ambivalence about this

move quickly became apparent.

You are sort of 50% trying, you’re not reallyybe-

cause diabetes is not like a crook heart or you can’t

move or you know. You can sort of go through your

life without being handicapped and then all of a

sudden you get your leg chopped off or some-

thingyWhich frightens you when you see people

that do that you know. They don’t fully realise until

it’s too late.

The shifting pronouns in this narrative portray a sense

of an internal dialogue between the inner first person

(‘‘I’’) and a reflexive second person (‘‘you’’) (Bakhtin,

1981). Such an inner dialogue communicates the

ambivalent subjectivity of the speaker, the constant

self-reflexivity and surveillance required to manage

diabetes, the struggle to overcome habitual ways of

being in the world. It points to several possible identities,

in this case Sam choosing to rebel against medical

authority, Sam who chooses to ‘‘do the right thing’’, and

a possible future Sam disabled by the consequences of

the progression of his disease. The contradictions and

different orientations evident here speak not only of the

practical difficulties in deciding how to eat or act with

diabetes, but also of the speaker striving to reconcile the

uncertainties of his condition and its management into

his identity.

The ambivalence surrounding diet evident in Sam’s

statements is evident in many of our interviews.

Respondents thus participated in the widespread con-

flation of diet and morality in contemporary culture,

and many people spoke explicitly of feeling guilty about

not adhering strictly to a prescribed diet. Shirley

(diagnosed approximately 5 years before our interview)

said ‘‘you used to think oh, well what the heck! I’ll have

a piece of cake ynow you sort of think, no I can’t have

that. And if I did have it I’d feel so guilty about it’’.

Deviation was construed in overtly moral terms by

another woman who spoke of the effect of attending the

support group: ‘‘If you’re going to make a slip, you

come again [to the group] and you realise you’re guilty’’.

Although positive evaluations of oneself and one’s

eating are generally equated with sticking to the diet, the

evaluation of foods as good or bad can be contradictory.

For many diabetics, good food becomes an ambiguous

term, signifying both something that tastes good, and

also things that is healthy or approved (good for you),

and these can become mutually exclusive categories.

When applied to themselves or their behaviour, good

usually meant exercising restraint, self-control, in which

case, good food is what is approved for diabetics.

However, they also described good food in ways that

implied very different connotations. ‘‘You have to give

up all those good things’’, said Rosa, referring to the

sacrifices involved in relinquishing the pleasures of rich

and sweet foods. In this context, good relates to enjoying

the taste and texture of what were for some participants

the pleasures of a lifetime which were now to be

eliminated from the diet.

Salvation through hyper-compliance

In such talk, one detects a common theme reinforced

by health professionals and organisations such as

Diabetes Australia: the possibility of salvation through

compliance. Around half our sample said they coped

with diabetes by striving—at least sometimes—to con-

form strictly to the prescribed regime. Several had taken

on very public roles in their local branch of Diabetes

Australia, which embeds them in a subculture whose

norms and ideologies permit members to build positive

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–23822378

moral images of their management strategies. If health

behaviour and lifestyle are implicated in the disease,

then these people would do everything possible to

minimise its health impact. Strict compliance was

framed by a number of participants as following the

advice of the ‘‘experts’’ and as a reliable route to

successful management and prevention of complica-

tions. Even if it was not a foolproof recipe for

maintaining consistent BSLs, rigorous adherence went

some way towards exonerating them from blame for the

fluctuations, at least in their own mind. A common

theme in their interviews was the grave danger to the

large number of people who ‘‘have diabetes and don’t

know it’’. Several respondents had been very overweight,

and their diagnosis prompted a dramatic change in their

diet and way of life which a few described as ‘‘the best

thing that ever happened to me’’. Such a transformation

rhetorically positions the speaker as one of the ‘‘saved’’.

Fred was particularly dramatic in his description of how

he had altered his life in response to his diagnosis:

If they told me to eat grass for the rest of my life, I

would eat grass for the rest of my life as long as I can

stay healthyy I’m black and white. Half way isn’t

good enough when it comes to your health.

Miserable life of denial

Nevertheless, the theme of salvation through com-

pliance is double-edged because control is equated with

denial. A corollary of this theme is that people ‘‘who do

the right thing’’ are associated with images of meanness,

social isolation and deprivation. As Oscar asks: ‘‘Do I

do everything 100 per cent right and have a miserable

time or do I do everything wrong and die of kidney

failure in two or three years’ time. It’s a decision that I’m

in the process of making now’’. His debate between right

and wrong signals that he defines the choice he faces as a

moral decision. Oscar asserts his agency in making that

choice between a life of grim renunciation or one in

which he risks accelerating the long-term complications

of his disease. Hyper-compliance might please service

providers and protect against one kind of spoiled

identity, but it makes people vulnerable to another:

negative judgements from fellow diabetics or non-

diabetic friends. This is exemplified in the scornful

depictions of the ‘‘goodie goodies’’ as wretched souls

who spoil social events or police other people with

diabetes. Harry does not want to become ‘‘a boring type

person but a very good diabetic’’. Socialising and

enjoying oneself may be valued more highly than health,

so people sometimes opt for doing ‘‘the wrong thing’’.

For example, Mark was interviewed with his wife and

twin brother Neville (who also has diabetes). All three

members of this family were very critical of a relative

who ‘‘won’t go out to eat, won’t go for a holiday.

Diabetes rules her lifey she is panicked about

ityYou’ve got to compromise’’, they agreed. Because

eating is usually a social event and is always imbued with

social meaning, prohibitions on rich and sweet foods

entail a social loss.

Indeed, these values are strongly associated with how

people may perceive their healthiness. Canadian re-

searchers reported that lay definitions of ‘‘being

healthy’’ are intimately bound with definitions of what

it is to be an active, functioning social being. They

distinguished between people’s definitions of health as

an abstract state of being (where eating rich foods is

‘‘bad’’ for health) and a person’s ability to meet the

demands of daily life (where the social benefits from this

behaviour may contribute to their sense of healthiness)

(Eyles & Litva, 1994). This division parallels closely the

distinction between health and well-being. Diabetics in

Maclean’s study conformed to the diet when it did not

compromise their social functioning, but ‘‘when the

pursuit of health conflicted with well-being individuals

took liberties with the diet in order to miminize its

impact’’ (Maclean, 1991, p. 689).

Child parody

Many people’s accounts of their management in-

volved a parodic positioning of themselves as children,

thus expressing the diminished agency they experience in

their management of diabetes. The frequent use of the

word ‘‘naughty’’ is one example. Quentin scolded

himself, ‘‘naughty, naughty’’, for not taking his tablets

consistently. Irene confessed, ‘‘When I get naughty,

mine [blood sugar] shows up’’. Many participants used

the word ‘‘naughty’’ to describe diverging from the

recommended regimen, particularly with reference to

eating foods they see as proscribed. Peanuts, for

instance, were described as ‘‘naughty but nice’’. People

also often referred to things they were ‘‘allowed to eat’’

or foods they ‘‘could’’ and ‘‘couldn’t’’ have, words that

seem more appropriate in the description of feeding a

child than in talk about a mature adult’s eating: ‘‘They

let you eat some of your little treats’’. As in this case,

such language evoked a generalised authority ‘‘they’’.

Participants also applied the term ‘‘allowed’’ to permis-

sible blood sugar levels. ‘‘You’re allowed to go up to 10

once in a while’’ (Walter).

This image involves a somewhat playful caricature of

how they are spoken to by diabetes educators, doctors,

and dieticians who tell them how to eat, how to live, and

what they can and cannot have (although how light-

hearted varied from speaker to speaker). In rhetorically

positioning themselves as children, they are talking

about the power differential implicit in their relation-

ships with health professionals and parodying the very

language health professionals tend to use with older

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–2382 2379

people in particular. For example, Jim (age 68) described

himself as ‘‘Basically, I’m a good boy’’.

Such language simultaneously evokes both an image

of children as blameless innocents who are not

responsible for their condition, and also the ways in

which children are taught to become responsible for

their own actions. People with diabetes have had their

agency as adults diminished both by the health services

who admonish them to change their ways, and also

because they recognise that they must learn new ways of

being responsible for themselves. Several participants

admitted that they ‘‘know better’’, another phrase

reminiscent of language used to scolding a child. ‘‘You

say to yourself, ‘Oh you know you know better’ and you

just keep on eating the same way’’ (Sam). In Penelope’s

(a 65 year old retired secretary) description of how she

would try to manage her diabetes better (another

redemptive tale), she explicitly makes a comparison

between what she describes as her previous immaturity

and her conscious decision to start ‘‘being adult to

myself. It’s stupid the way I had been treating it. I’ve

been like a child actually. I’ve been denying it all and it’s

not going to go away and it’s not going to get better and

the good tooth fairy isn’t going to come and just help

me. Just a matter of being sensible and saying, look, get

your act together’’.

Here, Penelope the adult quotes herself scolding

Penelope the child/rebel. Her narrative continued this

metaphor in her description of her frustration and

anxiety at the difficulties she experienced in managing

her persistently elevated blood sugar levels. ‘‘It’s

frightening when you see them altogether. Like there is

no rhyme or reason that I can work out, when you are

being good, why does it suddenly go up. And you look

there and you think, I’ve eaten the right food, I’ve eaten

regularly yWhy does it?’’ She went on to say explicitly:

‘‘I mean, I suppose it’s the childish mentality. I’ve been

good, why aren’t I being rewarded?’’

As these quotes show, people’s talk shifts ambiva-

lently between childlike language which diverts blame,

gently mocks their positioning by health service provi-

ders, and the requirement that they ‘‘grow up’’ and

manage properly. At the same time, paradoxically, it

implies their adult status (and implicit moral agency) as

the reason for diverging from the prescribed regime

rather than conforming.

Normalisation

Becker (1997) identifies the moral force of normalising

ideologies for people whose lives are disrupted by

illness and difference from others. He suggests people

struggle continuously in their accounts between this

difference and the desire for normalcy. In diabetes,

the difficulties of management are reframed as people

described their refusal or inability to comply with

the restricted regime or failure to control their BSLs as

the ‘‘normal’’ experiences. Becker notes that such stories

are usually emplotted around an alternate ideology or

value: in this case, the positive values of pleasure,

larrikinism, or inverting the meanings of responsibility

and control.

For example, participants told us that ‘‘most’’ or ‘‘all’’

diabetics deviate from the regimen, thus presenting their

own lapses from a more understandable perspective.

When Sam said, ‘‘You reject that you’ve got it for a

start. Everybody doesyEvery diabetic goes into de-

nial’’, he was claiming that there was nothing unusual in

the fact that he took several years to decide to respond

seriously to the recommendations from a diabetes

educator. Harry (quoted above), who proposed that

‘‘everybody’s got it’’, was making a similar claim. ‘‘I’m

no angel, I do go off the diet occasionallyy I think all

of us do’’, said Denise.

Even if other people did not share exactly the same

weaknesses, they had their own versions. ‘‘I know I

shouldn’t drink wine but I think that is part ofy the

problem with diabetes too. I don’t know if abstainers get

it ever, or whether they have so much sugar in their

dietyThere is a lot of people, they don’t have alcohol,

they love sweet things, or fatty things or whatever’’.

(Tom, a pharmacist, diagnosed recently). If all people—

or at least all diabetics—do the same prohibited things,

then the speaker’s behaviour is rendered ordinary,

diminishing the potential moral stain. Eric, who used

the phrase ‘‘goodie goodie’’ to describe people who

strive for strict compliance, suggested that ‘‘maybe one

person in 100’’ actually adheres consistently to what is

recommended.

Many of the factors discussed above in describing

external causes of diabetes could equally be construed as

cases of normalising. For example, Fred’s references to

ageing and the ‘‘break down’’ of the pancreas evokes a

view of diabetes as almost a normal part of ageing, a

mechanical image of body parts as wearing out from

use.

Concealing transgressions

A small number of people admitted to concealing

their transgressions from service providers by manip-

ulating their medication or their self-monitoring of

blood sugar levels. That is, they consciously managed

not their disease, but the appearance of normality.

This perhaps alarming finding is similar to a study

conducted in the USA (Ferzacca, 2000). Like the

American Veterans in Ferzacca’s research, a few of

our respondents admitted disguising their problems by

recording false readings, by timing measurements

strategically (when they knew the level would be

better), or omitting testing when they thought their

BSLs would be elevated.

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–23822380

You get cunning too, you do it at the times you know

you are going to be better. All diabetics are the same

I knowy.I think you do get cunning, you know, and

you know when you are going to be worsey.You

probably avoid doing it at that time, you know it

looks better on your book. I know from looking at

other people’s books, they will do it, like, before tea

of a night and before breakfast or something because

you get better readings, you get to know that. (Sam)

In this admission, Sam normalises his behaviour,

detecting similar guilty secrets from ‘‘looking at other

people’s books’’. It also places him rhetorically in the

position as someone who can outwit the professionals, a

larrikin rebel highly valued in Australian culture.

These are not na.ıve transgressions, however. Another

man who used extra insulin or avoided testing himself

when he thought his sugars would be high commented

on the futility of these evasions, acknowledging, ‘‘You’re

only cheating yourself’’. A few others volunteered that

they knew people who manipulated the records of their

self-monitored blood sugar levels. ‘‘They think they can

get away with it’’, Ann said. But these respondents

insisted they did not do it themselves, and they

volunteered that they viewed this behaviour as futile

and counterproductive. ‘‘I mean, if I was silly enough I

could fake the ones I do, but you can’t fakeythe big

one’’ [referring to glycosylated haemoglobin, a blood

test ordered or taken by the doctor]. (Denise).

Such narratives of resistance to diabetes management

regimes may also invert the notion of ‘‘taking control’’

and ‘‘responsibility’’ promoted by health professionals.

It usually is understood to mean patients (rather than

doctors) taking responsibility for their own disease

management or prevention, that is, placing responsi-

bility with the people whose health is at stake. But the

form of agency implied in the invitation to ‘‘take

control’’ is limited; this form of responsibility entails

compliance with advice from health professionals and

recognition of their authoritative knowledge. The notion

of people ‘‘taking control’’ may also imply refusing the

authority of health professionals. For example, Sam and

Peter both reclaimed their autonomy in the management

of their diabetes by asserting the authority of embodied

experience over abstract expertise: ‘‘You don’t have to

accept everything the doctor says, but you can also just

resist. It’s your body. You can see for yourself what you

can do, what you can’t do. What you can have,

what you can’t have. And it helps’’ (Peter). Sam took

a similar view:

You look at Rosemary Stanton [media nutritionist],

she looks about 103, and she lives on no meat and

you know, soy..what they say is not absolutely

right. They don’t know. It’s only just now they’ve

realised all this GI factor and all that. When I started

off as a diabetic I can remember the girl up here

saying you’ve got to live on rice and you’ve got to do

this. And now they tell you the worst thing you can

eat is rice.

Sam went on to reinstate his experiential knowledge

(‘‘You know from your own experiencesyyou soon

realise what’s good for you and what’s not’’), also

relying on talking to other diabetics and extensive

reading. Their critique challenges the image of medical

science as a united, authoritative source of singular

truth. Research shows that publicised scientific debates

and fluctuations in health recommendations provoke

distrust and scepticism (Lupton & Chapman, 1995), as

well as creating gaps within which lay people can recover

a sense of agency from professional dominance (Broom

& Woodward, 1996). Such verbalisations of deviance

simultaneously accept and invert the appeals to indivi-

dual responsibility for health through an assertion that

they are carrying responsibility for their health and have

made their own choices. It also entails a resistance to

medicine’s authority to define health risks and accep-

table lifestyles.

Conclusions

Control is simultaneously a biomedical statement

about the management of blood sugar levels, a descrip-

tion of responsible compliance with medical regimes, an

ability to manage other life stresses, and the triumph of

the rational self over the disorder of the physical body

(Broom, 2001). It is intimately related to moral under-

standings of individual responsibility to be as healthy as

possible.

Interviews with diabetics show how moral identity is

negotiated through what is often a contradictory

language of control, surveillance, discipline, and respon-

sibility. People frequently discuss diabetes-related beha-

viour in terms that position themselves or others as

disobedient children, or as wicked or foolish, thus

eroding the very agency service providers acknowledge

to be central to successful management. These references

occur alongside appraisals of the social complexity of

‘‘compliance’’ with diabetic regimens and the difficulty

of achieving effective control over blood sugar levels

(Buttfield, 1993).

Living with diabetes involves many aspects of people’s

daily lives, and imposing control can be a multifaceted

and challenging process. Consequently, the management

of blood sugar is not just a technical matter, but a

complex and dynamic personal task for people with

diabetes. Close inspection of lay discourses about

diabetes reveals the difficulties, contradictions and

occasional unintended consequences of the frequent

use of exonerating language that diabetics deploy to

resist spoiled identity. The narratives of these people

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–2382 2381

living with diabetes display a constant struggle to

integrate and ‘‘make sense of the disorder’’ (Williams

& Wood, 1986, p. 1435). They yearn to order the chaotic

linkages between their endlessly mobile blood sugar

readings, the physical ways in which diabetes is

subjectively experienced, and how they live their lives.

When people with diabetes speak of ‘‘control’’, they

simultaneously employ two discourses. They call upon

the language of biomedicine used by clinicians and

diabetes educators; but they also evoke metaphors about

the disorder of the illness experience and about the

diabetic’s desire to assert a positive identity and agency

in the management of their disease. The idiom expresses

the subjective emotions of their relationships to the

disorder and the changes in personal identity and

lifestyle it entails. The language of control is a public

cultural code in which ‘‘being in control’’ is highly

valued. To be in control denotes power and agency,

while being out of control signals chaos, madness, and

moral failing.

The frequent references to control and its multiple

meanings thus form a central part of the moral discourse

surrounding diabetes. Efforts to protect themselves

from the stigmatising potential of diabetes may inad-

vertently undermine the agency of people who are

already coping with a demanding discipline and a

potentially disabling or life-threatening disease. They

might be more effectively supported by discourses

and services that strive to restore agency without

implicit or explicit judgement, and that dispute the

common cultural currency that blames people for

their health problems.

Acknowledgements

We are grateful to the New South Wales Department

of Health, and to the General Practice Evaluation

Program (Commonwealth Department of Health and

Ageing) for funding this research; to Julia Byford,

Anne Hirst, Angela Lehman, and Bruce Missingham

for assistance with data collection; to Julie Clark,

Emily Mauldon, and Anna Olsen for help with coding;

and to the editor and two anonymous reviewers for their

thoughtful and detailed comments on an earlier draft.

References

Bakhtin, M. M. (1981). In C. Emerson, & M. Holquist (Trans.).

The dialogic imagination. Austin: University of Texas Press.

Battaglia, D. (1995). Problematizing the self: A thematic

introduction. In D. Battaglia (Ed.), Rhetorics of self-making

(pp. 1–15). Berkeley: University of California Press.

Becker, G. (1997). Disrupted lives: How people create meaning in

a chaotic world. Berkeley: University of California Press.

Broom, D. H., & Woodward, R. (1996). Medicalisation

reconsidered: toward a collaborative model of care.

Sociology of Health & Illness, 18(3), 357–378.

Broom, D. H. (2001). Public health, private body. Australian

and New Zealand Journal of Public Health, 25(1), 5–8.

Buttfield, B. (1993). Living with the medical discourse of diabetes

mellitus: The social construction of chronic illness. Unpub-

lished Ph.D. thesis, Flinders University.

Colagiuri, S., Colagiuri, R., & Ward, J. (1998). National

diabetes strategy and implementation plan. Canberra:

Diabetes Australia.

Davison, C., Davey Smith, G., & Frankel, S. (1991). Lay

epidemiology and the prevention paradox: The implications

of coronary candidacy for health education. Sociology of

Health & Illness, 13(1), 1–19.

Davison, C., Frankel, S., & Davey Smith, G. (1992). The limits

of lifestyle: Re-assessing ‘‘fatalism’’ in the popular culture

of illness prevention. Social Science & Medicine, 34(6),

675–685.

Estroff, S. E. (1993). Identity, disability, and schizophrenia: the

problem of chronicity. In S. Lindenbaum, & M. Lock

(Eds.), Knowledge, power, and practice: The anthropology

of medicine and everyday life (pp. 247–286). Berkeley:

University of California Press.

Eyles, J., & Litva, A. (1994). Health or healthy: Why people are

not sick in a southern ontarian town. Social Science &

Medicine, 39, 1083–1091.

Ferzacca, S. (2000). ‘‘Actually, I don’t feel that bad’’: Managing

diabetes and the clinical encounter. Medical Anthropology

Quarterly, 14(1), 28–50.

Goffman, E. (1963). Stigma: notes on the management of spoiled

identity. New York: Prentice Hall.

Hunt, L., Browner, C., & Jordan, B. (1990). Hypoglycemia:

Portrait of an illness construct in everyday use. Medical

Anthropology Quarterly, 4(2), 191–210.

Kassenbaum, G., & Bauman, B. (1965). Dimensions of the sick

role in chronic illness. Journal of Health and Social Behavior,

6, 16.

Kleinman, A. (1978). Concepts and a model for the comparison

of medical systems as cultural systems. Social Science &

Medicine, 12(2B), 85–93.

Lupton, D., & Chapman, S. (1995). ‘‘A healthy life-

style might be the death of you’’: Discourses on diet,

cholesterol control and heart disease in the press and

among the lay public. Sociology of Health & Illness, 17(4),

477–494.

Maclean, H. M. (1991). Patterns of diet related self-care in

diabetes. Social Science & Medicine, 32(6), 689–696.

Martin, E. (1994). Flexible bodies: Tracking immunity in

American culture from the days of Polio to the age of AIDS.

Boston: Beacon Press.

Mathews, H. F., Lannin, D. R., & Mitchell, J. P. (1994).

Coming to terms with advanced breast cancer: Black

women’s narratives from eastern north carolina. Social

Science & Medicine, 38(6), 789–800.

Mattingly, C. (1998). Health dramas and clinical plots: the

narrative structure of experience. Cambridge: Cambridge

University Press.

Metcalfe, A. (1993). Living in a clinic: The power of public

health promotions. Australian Journal of Anthropology, 4(1),

31–44.

ARTICLE IN PRESSD. Broom, A. Whittaker / Social Science & Medicine 58 (2004) 2371–23822382

Parsons, T. (1951). The social system. Glencoe, Il: The Free Press.

Posner, T. (1977). Magical elements in orthodox medicine:

diabetes as a medical thought system. In R. Dingwall, C.

Heath, M. Reid, & M. Stacey (Eds.), Health care and health

knowledge (pp. 142–158). London: Croom Helm.

Riessman, C. K. (1990). Strategic uses of narrative in the

presentation of self and illness: A research note. Social

Science & Medicine, 30(11), 1195–1200.

Scheper-Hughes, N., & Lock, M. M. (1987). The mindful body:

A prolegomenon to future work in medical anthropology.

Medical Anthropology Quarterly, 1(1), 6–41.

Sontag, S. (1978). Illness as metaphor. London: Allen Lane.

Stein, H. F. (1985). The psychodynamics of medical practice:

unconscious factors in patient care. Berkeley: University of

California Press.

Whittaker, A. (2002). ‘‘Heart trouble’’: Negotiating risk and

identity in an Australian suburb. Asia-Pacific Journal of

Anthropology, 3(1), 101–122.

Williams, G. (1993). Chronic illness and the pursuit of virtue

in everyday life. In A. Radley (Ed.), Worlds of illness

(pp. 92–107). London: Routledge.

Williams, G., & Wood, P. (1986). Commonsense beliefs

about illness: A mediating role for the doctor. Lancet, ii,

1435–1437.