Andrew Burchell examines what advertisements in patient organisation magazines reveal about medical consumerism and the globalisation of diabetes care.
In 1980, the Swedish Diabetes Association (Svenska Diabetesförbundet or SDF) informed the readers of its magazine about a change in advertising policy. From now on, Diabetes would not publish any advertisements for food products which “imply that diabetics – in relation to non-diabetics – have separate needs or wishes” (antyda att diabetiker – i förhållande till icke-diabetiker – har särskilda behov eller önskemål). Simultaneously, advertisers would need to provide breakdowns of energy content and the artificial sweeteners employed in their products (SDF 1980, 40). If the SDF relied on advertising to supplement the magazine’s running costs, its relationship with the companies footing the bill was therefore not always smooth.
The moulding of people with diabetes into consumers was a complex process and one that is of interest to us on the ActDisease (Acting Out Disease) project. We are exploring patient organisations, which we define broadly as associations or self-help groups formed by people with the shared experience of health conditions. The project seeks to be doubly comparative: firstly, across several conditions (such as diabetes, rheumatism, allergy); and, secondly, across a number of Western European countries. We explore how patient organisations interacted with medical authority and how they transformed “patients” into groups with specific characteristics and assumed needs. A patient organisation for diabetes, for example, implicitly and explicitly shapes lines of inclusion and exclusion, determining who gets to be a “diabetic.” This is especially marked at the point where “care” meets “commerce” (see Mol 2008).
Diabetic organisations, periodicals, and didacticism
Associations for diabetes patients were among the earliest to form. The British Diabetic Association (BDA) was founded in 1934, largely under the leadership of R.D. Lawrence – a diabetes specialist who was himself diabetic – and a group of his middle-class patients. Its French counterpart, the Association française des diabétiques (AFD), founded in 1938, was dominated by medical actors and was much slower to embrace lay voices in its magazine. The Swedish association (initially the Riksförbundet för sockersjuka, and later the SDF) came into being in 1943, in the context of wartime debates around the future of diabetes care in neutral but isolated Sweden. In all cases, the organisations saw their roles as didacticism – educating people to be “good” diabetics (Moore 2020) – the provision of social care, and lobbying national governments for free insulin and equipment. National organisations can therefore be seen as a counterpart to the increasing globalisation of diabetes care (of which more later).
All three diabetes associations aspired to have a periodical in order to further these objectives, as well as to foster dialogue and community between members who were geographically dispersed within their respective countries. The extent of these aims fluctuated over time and between the different organisations, as did the format of the publications. However, one constant remained: advertising. Put simply, none of the journals – the BDA’s Balance, the AFD’s Journal des diabétiques (later Équilibre), and the SDF’s Diabetes – could exist without selling advertising space to producers of specialist products.
It is here that diabetes becomes a revealing case study. Advertisements should not just be considered marginal paratexts bolted onto the “main” text (composed of recipes, interviews, narrative, and advice) of these periodicals; rather, they deserve closer scrutiny as textual and visual sources. They can help to reveal tensions around the kinds of “diabetic people” these organisations aimed to create. Were they to be rational “expert” consumers, led by the organisations’ benevolent guidance, or impulsive shoppers, vulnerable to the forces of ad-men’s powers of persuasion? They also allow us to see how patient organisations acted as a bridge between members, states, medical specialists, and transnational actors (like healthcare companies).
Advertising treatments
One basic way of doing this is to explore what kinds of products were marketed to the readership. The middle years of the century were marked by the dominance of advertising for dietary products, which often favoured national manufacturers. In 1963, food and beverages accounted for 76 percent of all the advertisements inserted in Balance, 52 percent of advertisements in Diabetes, and 48 percent in Le Journal des diabétiques. But by the 1970s, food and drink advertisements were progressively overtaken within the magazine by new administration technologies for insulin – such as disposable plastic syringes – as well as blood glucose monitoring technologies produced by a narrower range of global manufacturers. In 1985, 69 percent of advertisements in Balance were for these technologies, compared to 50 percent in Diabetes, and 65 percent in Équilibre.
These shifts outline a relatively well-known, and global, story about the development of diabetes therapy and care. The arrival of more accurate and portable blood glucose monitors at the end of the twentieth century flipped the script inherited from the early insulin era (1922 onwards) regarding how diabetes should be treated. From carefully balancing carbohydrate to insulin intake, diabetics were now able to measure blood sugar in real time and instead balance insulin to the fluctuations of glucose. The need for specialist low-sugar products was therefore reduced at the same time as measurement technologies became integral to managing the condition. Advertising was key to mediating how people diagnosed with diabetes encountered these new devices and their treatment potential.
Moreover, advertising in the diabetes organisations’ periodicals predated the inclusion of such devices within welfare state systems, meaning that many who first encountered them through advertisements would see and consume them “privately.” That is, they purchased them with their own resources and developed a relationship to the technology in a consumerist (rather than purely welfare-state) context. This was true for blood glucose monitors and syringes, at least initially, but it was also true of food. Despite the associations’ efforts to instil knowledge about nutrition and food values, and to encourage members to see diet as core to their treatment, there was no external help with food costs.
These processes also testify to an increasing globalisation of diabetes care, and the concentration of the technology market into the hands of multinational brands. It is not uncommon, when reading across the British, French and Swedish periodicals, to find the exact same advertisements for a specific brand, using the same images and page layout, with the only immediate difference being the language of the copytext. Despite the harmonisation of visual languages imposed by these globalisation processes, however, it would be wrong to view the advertisements simply as transnational impositions. The products advertised were always in dialogue with national welfare-state systems, which invariably determined a patient’s access to these products.
Global advertising, national contexts
If advertising campaigns could be adapted to local factors, local contexts enabled patients to appropriate advertising languages for their own purposes. Plastic syringes offer a productive example of this. Treatment of diabetes by insulin injections originally employed glass syringes and reusable needles. A circular economy predominated: with needles sharpened, syringes sterilised, and access (generally) subsidised by the welfare state. While the disposable insulin syringe entered the market in all three countries during the 1960s, welfare states varied in their pace of integrating it into subsidised care. In Britain, disposable syringes were not universally available under the National Health Service until 1987; in Sweden, they were available free at the nationalised pharmacy monopoly from 1973; and they only gradually became reimbursable under the French social security system during the early 1970s. Advertisers were aware of these differences and they seeped into the national specificities of the advertising.
One campaign by the American syringe manufacturer Becton-Dickinson featured a pair of hands clasped around the syringe and appeared in the periodicals of all three countries between 1984 and 1986. Yet, on closer inspection, while the background image was constant, the syringes were different. Without a clear international standard of insulin measurement at this time, the gauges on the sides of the syringes had to be adapted to reflect the standards within the respective countries. Moreover, in Britain, this advertisement was for a private product being sold to diabetic patients for purchase with their own disposable income. It was a luxury item and a political object, with frequent campaigning and lobbying for its provision a cornerstone of BDA policy. In this way, the advertisement’s inclusion in the BDA’s magazine served multiple different readerships and purposes. Becton-Dickinson’s claim that the syringe promised comfort and smoothness for its users offered readers an appealing advertisement that they (and we) could take at face value. But its claims were also political and bolstered the BDA’s long-running campaign for free access to the devices. This was not the case in the French or Swedish advertisements, where the appeal to comfort was obviously more of a marketing tactic, but spoke – at least in the Swedish example – to a more general organisational concern with promoting “painless” injections.
The advertisement of injection technologies thus reveals how the language of commercial texts was not separate from, but fundamentally in dialogue with, the “other” parts of the magazine and the national contexts in which the BDA, AFS, and SDF were implicated as actors. As much as the didactic information on how to give oneself an injection or carefully weigh food and carbohydrate content, advertisements were productive texts through which people with chronic health conditions had their identities shaped. When the SDF informed readers of Diabetes about the potential for “painless injections” (smärtfria injektioner) offered by jet injection technologies in 1949, it noted that the very term “may be felt with hope by the many diabetic patients for whom the daily insulin injections can, of course, not be pleasant” (må kännas hoppfulla för de många diabetespatienter, för vilka de dagliga insulin-injektionerna givetvis inte kan vara något behagligt) (RfS 1949, 6). Framing injection fundamentally as a welfare problem – in which the organisation could provide advice on technique, but also lobby for access to technologies – actually went together with more consumer-based demands which centred the improvement of individual experiences. In other words, the “diabetic as consumer” offers a more complex and nuanced story of the emergence of globalised neoliberal healthcare, in which manufacturers had to negotiate national specificities and demands for consumer goods that were often articulated in welfare contexts.
Advertising in patient organisation magazines provides a unique vantage point for considering the dialogue of national and global factors in healthcare. Arising from an economic imperative to ensure the financial sustainability of the periodicals, the presence of advertising existed in dialogue with other content in the magazine, whether in the form of dietary guidance or discussions of pain. Advertising and other content mutually influenced each other. It was not simply about economic resources and funding passing from companies to the patient organisations, it was also a way to help the organisation assert narratives around personal independence. As the opening example of the SDF magazine suggests, organisations actively shaped their own advertising policies. This process also shaped what diabetes itself was, and what its imagined treatment should be. It is therefore worthy of note that many of the patient periodicals that we study have ceased publication, as organisations – and advertisers – move their advice and engagement online and onto social media. It remains to be seen what kinds of patient identities emerge in this context, and how they will respond to the push-and-pull of national and global influences.
About the author
Andrew Burchell is a postdoctoral researcher on the ActDisease project, based in the Department of History of Science and Ideas at Uppsala University, Sweden. His work explores patient organisations as mediators of patient experience, with a developing interest in patient consumerism. He also works on the history of stammering.
References
RfS (Riksförbundet för sockersjuka). 1949. “Strål-injektion.” Diabetes 3: 6–8.
Mol, Annemarie. 2008. The Logic of Care: Health and the Problem of Patient Choice. Routledge.
Moore, Martin D. 2020. “Balance and the ‘good’ diabetic in Britain, c.1900-60.” In Balancing the Self: Medicine, Politics and the Regulation of Health in the Twentieth Century, edited by Mark Jackson and Martin D. Moore. Manchester University Press.
SDF. 1980. “Ny annonspolicy i Diabetes.” Diabetes 1: 40.
