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Chapter 3 relies on data from in-depth interviews with clinicians and members of the general public, participant observation, and a review of Japanese popular intellectual literature to examine narratives about the origins of diabetes in Japan. It argues that the most pervasive Japanese narratives emphasize the particularity of diabetes risk to Japanese bodies. This narrative implies that illness arises from a disconnect between Japanese bodies and non-Japanese food culture. The road to health is a return to an imagined traditional Japanese lifestyle that has been lost to globalization and westernization. Rather than stressing individual responsibility and temptation, dominant Japanese narratives stress a shared struggle against outside forces.

This chapter uses interview data with American health care providers to examine clinicians’ strategies for negotiating with patients to elicit cooperation and participation in their own self-management. It argues that physicians in both countries switch between different models of the provider-patient relationship as they see fit to the situation. The American providers stressed that, ultimately, responsibility for managing the disease rested with the patient. However, they were markedly pessimistic about their patients’ capacity for change and likely course of disease progression. Providers’ low expectations and pessimism contributed to a preference for small, simple lifestyle changes in combination with medication rather than bold lifestyle change.

Over the last twenty years, type 2 diabetes skyrocketed to the forefront of global public health concern. In this book, Mari Armstrong-Hough examines the rise in and response to the disease in two societies: the United States and Japan. Both societies have faced rising rates of diabetes, but their social and biomedical responses to its ascendance have diverged. To explain the emergence of these distinctive strategies, Armstrong-Hough argues that physicians act not only on increasingly globalized professional standards but also on local knowledge, explanatory models, and cultural toolkits. As a result, strategies for clinical management diverge sharply from one country to another. Armstrong-Hough demonstrates how distinctive practices endure in the midst of intensifying biomedicalization, both on the part of patients and on the part of physicians, and how these differences grow from broader cultural narratives about diabetes in each setting.

Chapter 2 synthesizes scholarly work on diabetes narratives, a discussion of popular literature on diabetes, and interview data. It argues that the dominant American narratives on the origins of the diabetes epidemic emphasize the universality of risk and rely on the perception that illness arises when one treats the body in ways that are unnatural. The price of modernity, according to this origin story, is stress and the constant temptations of a sedentary lifestyle and unwholesome foods—indulgences that, because they are unnatural, cause harm to the body. Because everyone is imagined to be exposed to risks of modernity, mitigating risk is a matter of personal discipline; those that fall victim to so-called lifestyle diseases are implicitly or explicitly cast as morally culpable for their disease.

This chapter introduces the type 2 diabetes epidemics of Japan and the United States, noting national differences in response to the epidemics among medical, public health, and patient communities. It summarizes the tradition of approaching medicine as a social enterprise in the social sciences, describes the organization of the book, and motivates its central theoretical and empirical questions.

This concluding chapter summarized the central argument of the book: Biomedicalization does not flatten out differences so much as it proliferates them. As the biomedical paradigm has become central to lay systems of meaning, the language and ideas of biomedicine are imbued with cultural meanings. In this way, medicine shapes and reorganizes cultural meanings. But the reverse also occurs: the cultural meanings that arise from lay systems shape the patient-provider encounters and narratives that lie at the heart of the practice of medicine. These meetings of lay and medical systems of meaning are sense-making events in which patients and providers “practice culture.” In the United States, biomedicalization and a capitalist ethic of productivity and individual responsibility become mutually reinforcing: the individual is continually reinscribed as the primary category of being and the object of medicine. In Japan, biomedicalization intertwines with discourses of nationhood, membership in a purportedly unique racial-cultural community, and gendered domestic labor. While biomedicalization does not flatten, its targets are reshaped in traceable ways by the cultural repertoires that inform it. As biomedicalization renders interactions between providers and patients more uncertain and more collaborative, the cultural resources that they bring to those encounters become more—not less—relevant.

This chapter examines Japanese providers’ strategies for managing patients with diabetes using interview data and participant observation from full-time clinical shadowing of outpatient and inpatient exams at three major health centers, diabetes education classes, medical staff meetings, all-hospital assemblies, and dialysis center activities. While American health care providers spoke privately about diabetes and patients with diabetes in pessimistic terms, Japanese providers maintained high expectations and hopes for type 2 diabetes outcomes, even in private when they were not cheerleading patients. Providers in Japan imagined the origins and inevitable progression of diabetes differently from their peers in the United States, rendering them more optimistic about patients’ futures and more likely to favor lifestyle change.

This chapter uses interview data collected from Japanese patients, members of the general public, and health care providers to examine personal explanatory models and illness narratives surrounding type 2 diabetes. Participants articulated a model of health that revolves around the idea of an “ordered” life. In particular, order comes from careful adherence to a classification of time and relies on a clear division of domestic labor. Having a “rhythm” to one’s life, and observing regular, unchanging hours for core activities like waking, eating, and bathing were identified as key to a healthy life. But the responsibility for this temporal maintenance falls largely on women: women work to organize the time of loved ones into a healthy, regular rhythm. Men without mothers, wives, sisters, or daughters to take care of them are thus thought to be particularly at risk of illness.

This chapter presents a discussion of the book’s theoretical framework and central argument, arguing that the everyday practice of biomedicine and the social process of biomedicalization rest on the foundations of relatively widely shared narratives within communities. As these narratives and narrative fragments are accessed selectively and deployed with creativity and contradiction, the transformations social scientists call biomedicalization are necessarily inflected and informed by their sociocultural context through what is available from the cultural repertoire or “tool kit” and how those cultural materials are deployed. As a result, biomedicalization does not eradicate diversity in “things medical,” but rather produces it. The following chapters explore this argument empirically, organized in descending order of imagined social space: world, nation, exam room, and home. Each is a site at which the meaning of the diabetes epidemic is imagined, negotiated, contested, and reimagined.