Managing uncertainties: An ethnography of diabetes management in Malawi

Diabetes is a chronic condition characterised by raised levels of blood glucose in the body due to its inability to produce any or enough, or effectively use insulin. It is a growing problem worldwide, with over 425 million people living with it, 79% of whom live in low and middle-income countries. This thesis shows how patients experience, live with, and manage diabetes as a form of uncertainty. It is based on twelve months of ethnographic fieldwork using interviews, participant observation, and informal conversations in patients’ homes, herbal and diabetes clinics at a rural mission hospital and a referral teaching hospital in the Southern Region of Malawi.
Few studies have explored diabetes and its management using qualitative or ethnographic methods in Malawi, and most African countries. Mostly, studies have quantitatively assessed knowledge, ‘experiences’ of living with diabetes, ‘quality’ of care and highlighted barriers and challenges of diabetes management among health care workers and patients. Anthropological studies of diabetes, mostly from Western countries, characterise its management as “tinkering” – highlighting changes and adjustments in practices that are meant to suit patients’ bodies and circumstances, and ‘bio-tactics’ – patients’ idiosyncratic strategic negotiation, implementation and recalibration of self-management advice to make it relevant in social lives and “diabetes bodies liveable”. Studies on uncertainty reveal the pragmatics of managing it, and its productiveness in terms of envisioned futures, hope, and other uncertainties.
This thesis shows how people responded to the uncertainties of diabetes and its management within complex therapeutic landscapes in three ways: “experimenting”, improvising and “trying harder” within unique social relations. These modes of responses were mutually constitutive, overlapping and informed each other. The thesis argues that a distinct kind of “re-active patient” is being constituted in these circumstances. The “re-active patient” maintains aspects of “active patienthood” which requires medical literacy and taking care of him/herself, but also engages in a different repertoire of responses including “experimentation” and improvisation using herbal medicines, religion, and forms of reading their bodies.