The Violence of Abstraction

333 Pages·2017·28.71 MB·English

WWaasshhiinnggttoonn UUnniivveerrssiittyy iinn SStt.. LLoouuiiss
WWaasshhiinnggttoonn UUnniivveerrssiittyy OOppeenn SScchhoollaarrsshhiipp
Arts & Sciences Electronic Theses and
Arts & Sciences
Dissertations
Winter 12-15-2016
TThhee VViioolleennccee ooff AAbbssttrraaccttiioonn:: LLeeaarrnniinngg ttoo LLiivvee WWiitthh TTyyppee--22
DDiiaabbeetteess iinn EEvveerryyddaayy LLiiffee
Jenny Epstein
Washington University in St. Louis
Follow this and additional works at: https://openscholarship.wustl.edu/art_sci_etds
Part of the Anthropology Commons
RReeccoommmmeennddeedd CCiittaattiioonn
Epstein, Jenny, "The Violence of Abstraction: Learning to Live With Type-2 Diabetes in Everyday Life"
(2016). Arts & Sciences Electronic Theses and Dissertations. 986.
https://openscholarship.wustl.edu/art_sci_etds/986
This Dissertation is brought to you for free and open access by the Arts & Sciences at Washington University Open
Scholarship. It has been accepted for inclusion in Arts & Sciences Electronic Theses and Dissertations by an
authorized administrator of Washington University Open Scholarship. For more information, please contact
[email protected].
WASHINGTON UNIVERSITY IN ST. LOUIS
Anthropology Department

Dissertation Examination Committee:
Rebecca Lester, Chair
Pete Benson
John Bowen
Brad Stoner
Corinna Treitel

The Violence of Abstraction: Learning to Live With Type-2 Diabetes in Everyday Life
by
Jenny Epstein

A
 dissertation
 presented
 to

The
 Graduate
 School

of
 Washington
 University
 in

partial
 fulfillment
 of
 the

requirements
 for
 the
 degree

of
 Doctor
 of
 Philosophy

December 2016
St. Louis, Missouri
Table of Contents
List of Figures .................................................................................................................... vi
Acknowledgements ........................................................................................................... vii
Chapter 1: Introduction ........................................................................................................1
1.1 How this project began ......................................................................................4
1.2 Scope of the project ...........................................................................................8
1.3 Foucault, Lefebvre and the anthropology of diabetes ......................................12
1.4 The violence of abstraction ..............................................................................21
1.5 A closer look at Henri Lefebvre .......................................................................23
1.6 Overview of chapter .........................................................................................24
Chapter 2: Methods ............................................................................................................27
2.1 Historical analysis ............................................................................................27
2.2 Ethnographic data collection ............................................................................29
2.3 Analytic auto-ethnography ...............................................................................30
2.4 Life-history interview tool ...............................................................................32
2.5 Recruitment sites and population interviewed .................................................38
2.6 Participation in and observation of diabetes education programs ...................45
2.7 Conferences attended .......................................................................................46
2.8 Participant observation as a HealthCare Navigator .........................................48
2.9 Interviews with health care providers ..............................................................48
2.10 Media analysis ...............................................................................................48
Chapter 3: The Re-settlement of Tacoma ..........................................................................50
3.1 “Tacoma, City of Destiny!” Connecting the old and new ...............................52
3.2 The production of uniform social space ...........................................................57
3.3 The platting of a railroad town .........................................................................60
3.4 Organized labor and the downtown core .........................................................65
3.5 Manufacturing moves out of the downtown core ............................................67

 ii
3.6 Designation as a superfund site ........................................................................71
3.7 Loss of a city core ............................................................................................73
3.8 The rising local economic importance of healthcare .......................................74
3.9 Tacoma’s demographics and neighborhoods today .........................................80
3.10 The formation of diabetes corridors ...............................................................82
Chapter 4: Epidemiology and history of type-2 diabetes ...................................................85
4.1 Type-2 diabetes: a transmutable disease ..........................................................86
Chapter 5: Emergence of a Scientific Body .......................................................................93
5.1 Claude Bernard and the measurement of bodies ..............................................96
5.2 Creating a scientific subjectivity ......................................................................98
5.3 Insulin, self-discipline and the diabetic subject .............................................100
Chapter 6: Diabetes Education Programs ........................................................................112
6.1 Bodies in everyday life ..................................................................................113
6.2 Diabetes self-care skills .................................................................................117
6.3 American Pharmacy Association Diabetes Management program ...............119
6.4 Journey for Control: training for medical professionals ................................134
6.5 Journey for Control: observing group sessions .............................................138
6.6. Journey for Control: implications .................................................................142
6.7 Diabetes Expo, Seattle Expo…………………………………....…………..143
6.8 Concluding remarks .......................................................................................149
Chapter 7: General Description of Interviews .................................................................152
7.1 Work and patterns of social connection .........................................................157
7.2 The course of diabetes ...................................................................................161
7.3 Race/ethnicity/geography ..............................................................................163
7.4 Marriage and gender ......................................................................................164
7.5 The safety net of SSDI ...................................................................................166
7.6 Complimentary Alternative Medicine (CAM) and digital data trackers .......168
7.7 Patterns of control ..........................................................................................174

 iii
7.8 Concluding remarks .......................................................................................178
Chapter 8: Just Beginning ................................................................................................180
8.1 Disconnecting body from self: Laura’s story .................................................183
8.2 The power of food: Cedric’s story .................................................................195
8.3 The power of food: Susan’s story ..................................................................119
8.4 Giving responsibility to technology: Jerry’s story .........................................202
8.5 Re-defining self and self-care: Marie’s story .................................................206
8.6 Diabetes isn’t real life: Ima’s story ................................................................209
8.7 Concluding remarks .......................................................................................211
Chapter 9: Still Learning/Flux .........................................................................................213
9.1 Bouncing between extremes: Steve’s story ...................................................214
9.2 Contemplation as a double-edged sword: Rick’s story ..................................221
9.3 The bureaucracy of safety-net assistance: Earl’s story ..................................224
9.4 Discovering control: Jane’s story ...................................................................229
Chapter 10: Care of the Self .............................................................................................238
10.1 Finding pieces to a puzzle: Marie’s story ....................................................241
10.2 An American success story: Luis’ story ......................................................253
10.3 A lifetime of self-discipline: Sara’s story ....................................................258
10.4 The roles of medication and concluding remarks ........................................263
Chapter 11: Spirituality, Reciprocity and the Ethics of Self-care ....................................265
11.1 Spirituality....................................................................................................265
11.2 Volunteering and reciprocity .......................................................................273
11.3 Concluding remarks .....................................................................................277
Chapter 12: Affordable Care Act Coda ...........................................................................281
12.1 Self-objectification and self-care .................................................................283
12.2 Simplification, exclusion and power ............................................................285
Chapter 13: Conclusion ....................................................................................................291
References ........................................................................................................................301

 iv
Appendix 1 .......................................................................................................................319
Appendix 2 .......................................................................................................................320
Appendix 3 .......................................................................................................................321
Appendix 4 .......................................................................................................................322
Appendix 5 .......................................................................................................................323

 v
List of Figures
Figure 3.1: Tacoma! Gateway to Health! ..........................................................................53
Figure 3.2: “Looking up 11th Street” Downtown Tacoma, 1907 .......................................64
Figure 3.3: Wheeler-Osgood plant, circa 1927 ..................................................................68

 vi
Acknowledgements
This dissertation began decades before any fieldwork or writing took place, and so, to
acknowledge all of the help, insights, discussions and encouragement that has occurred over that
period would be impossible. However, I would like to try and acknowledge the people who stand
out in my mind now, thirty years after first becoming aware of the life-threatening consequences
of poorly controlled type-2 diabetes as a pharmacy student. Over this period, the people I’ve
encountered living with type-2 diabetes have been my most significant teachers. In particular, I’d
like to thank Ida for all of her insights of living with type-2 diabetes she has shared with me over
the decades of our acquaintance.
I would also like to thank my professors at Southern Methodist University, Carolyn
Smith-Morris, Caroline Brettell and Vickie Lockwood, for guiding me through the first years of
anthropology training and this project. At Washington University, in addition to the support of
Anthropology Department faculty and members of my committee, Carolyn Sargent has been an
integral part of this project from its beginning at SMU. In addition, I am most grateful for Jennie
Joe’s help at the beginning stages of this project and fieldwork and her sustained interest
continuing to its end. Finally, the completion of this dissertation would not have been possible
without the weekly meetings, support and particularly the direction to just “keep writing” from
my advisor, Rebecca Lester. Whatever shortcomings exist in the arguments of this dissertation
are my own responsibility and not from her lack of identifying them in thorough draft readings.
My thanks also go to a number of people outside of anthropology, whose involvement
facilitated my fieldwork and the writing process. Janet Runbeck’s energy and ability to network,

 vii
organize and follow through on a project is still a source of awe to me. She provided not only a
fieldwork site in Tacoma, WA, but also a template of how to realize a needed community service
despite being told “that can’t be done.” In addition, her willingness and interest to discuss all
manner of world, medical and personal issues provided much needed support during fieldwork.
Ruth Berson, at the Writing Center of Washington University provided a different, but equally
essential, template for student engagement and support provided during the final months of
writing. This dissertation could not have been completed without her critique, colored pens and
metaphors as to how to frame an argument. I cannot thank her enough for sharing her writing
expertise. I also owe a special thanks to Quynh-Chi Duong, pharmacist extraordinaire, for
helping me negotiate the vagaries of graduate school and for our long discussions about the
nature of clinical work and diabetes treatment.
Last and not least, one of the unexpected benefits of graduate school was that it made me
appreciate the depth of my father’s self-taught knowledge of philosophy and social theory. My
father’s passing, right as I began fieldwork, has made me grateful for what I was able to learn
from him, but also acutely aware of his absence, as someone not only knowledgeable but always
ready to take an interest in the details of my project. I hope this dissertation comes at least close
to his insightful way of understanding the world.

Jenny Epstein
Washington University in St. Louis
December 2016

 viii
Chapter 1: Introduction
Urban, industrialized space usually evokes images of a built environment that is intensely
human-made, of people living in close proximity and yet also isolated and anonymous. One
doesn’t immediately think of how the space and routines of daily urban life and human biologies
are closely intertwined or how urban life shapes the ways people take care of themselves and
each other. Yet these were the unexpected and profound connections I encountered among
residents of Tacoma, WA, living with type-2 diabetes. Closely interwoven into the routines of
daily life were loss and disenfranchisement, abstraction and alienation that brought into sharp
relief how little value was placed on caring for one’s health. Under the guise of changing simple,
daily routines were intense struggles to break the powerful hold of what was familiar and known,
and particularly, to find new meanings that made it worth the effort. How social spaces are
conceived, particularly the space of human bodies in urban settings is the underlying dimension
that links past and present, the local and universal to the ongoing narratives of progress and
development in this project.
Rick’s story of diabetes is one of struggle to regain a sense of place in the world and to
find new reasons to care for his health. “I’m blue-collar, I was busting my ass all my life. It’s
hard mentally, how to get back in.” Two years before I met Rick, he had lost his sawmill job of
30 years when X Corporation declared bankruptcy. “We all lost our jobs, we were all laid off.
They went broke; they said they had no money. Everyone lost their pensions, retirement. They
took it all away. There was no recourse. I mean they just packed up corporate headquarters in

 1