Sugar and Tension: Diabetes and Gender in Modern India

By Lesley Jo Weaver

Women in North India are socialized to care for others, so what do they do when they get a disease like diabetes that requires intensive self-care? In Sugar and Tension, Lesley Jo Weaver uses women’s experiences with diabetes in New Delhi as a lens to explore how gendered roles and expectations are taking shape in contemporary India. Weaver argues that although women’s domestic care of others may be at odds with the self-care mandates of biomedically-managed diabetes, these roles nevertheless do important cultural work that may buffer women’s mental and physical health by fostering social belonging. Weaver describes how women negotiate the many responsibilities in their lives when chronic disease is at stake. As women weigh their options, the choices they make raise questions about whose priorities should count in domestic, health, and family worlds. The varied experiences of women illustrate that there are many routes to living well or poorly with diabetes, and these are not always the ones canonized in biomedical models of diabetes management.  

• Language: English
• Publisher: Rutgers University Press
• Release date: Dec 10, 2018
• ISBN: 9781978803022

Book preview

TENSION

1 OPENING A WINDOW ON DIABETES EXPERIENCE

Maya had seen more suffering in her thirty-five years than many women do in a lifetime. Her husband had passed away suddenly five years earlier from an aneurism, leaving her a widow at age thirty with two young children. She and her husband had shared a house in a poor and congested area of Delhi with her parents-in-law, and after his death she had no choice but to continue living with them. The house was located down an alley lined on either side by open gutters where sewage and street dogs ran free. Because the alley was so narrow, it was only accessible by bicycle or on foot. As I walked on, flies buzzed, and the alley darkened to an eerie midday dusk lit only by a thin sliver of sky above. It dead-ended at the ground-floor apartment where Maya, her children, and her in-laws lived. The in-laws owned the building and made their only income by renting the upper floors. I stepped gingerly around bicycles and a motorcycle crowded around the front doorway, then ducked my head as I passed through. Faded pictures of Hindu gods and goddesses, draped with dusty dried garlands of marigolds, decorated the blue walls. Maya motioned for me to sit on the cot-turned-sofa that was the main piece of furniture in the living room, then returned with a tray holding a glass of cold water. She settled herself onto a low stool facing me. Although I was very uncomfortable with this arrangement, which seated me both symbolically and physically above her, she insisted.

I had met Maya at a diabetes clinic several weeks earlier, where she was accompanying her diabetic mother-in-law for a routine checkup. Assuming that Maya herself did not have diabetes because she looked so young, I asked if she might be willing to talk to me as a nondiabetic woman about her everyday life. To my surprise, she told me she was prediabetic: she had elevated blood sugar that would turn into diabetes if she did not change her diet and begin taking medication. Maya had received this diagnosis four and a half years before, just after her husband’s untimely death, but she had not been checked by the doctor on the day we met, nor for any diabetes-related care since that initial diagnosis. When I asked why, she said it would cost her in-laws extra money, which they would hold against her. Besides, they would probably suspect her of malingering to get out of household chores. She promised me, however, that she would see him in another two or three days.

Maya had had to ask permission from her father-in-law for me to visit her house that day. A moment after I arrived and sat down, her mother-in-law appeared in a doorway. Maya immediately covered her head with her dupatta as a sign of deference. I cheerfully introduced myself in Hindi and explained that I was visiting with Maya because I wanted to learn more about her health. The mother-in-law did not smile back and barely responded, but hovered with her arms crossed as if to monitor what Maya was telling me. The tension was palpable.

Maya knew she was an unlikely candidate for a prediabetes diagnosis based on her weight, age, and family history, so she looked elsewhere for explanations of her illness. She figured that the shock of her husband’s sudden death (and the stress of dealing with her in-laws alone thereafter) must have done it. Nobody had it in my family, I just had a lot of tension at that time. That’s why I got sugar, she said. When her mother-in-law left the room again, she continued in a lowered voice, leaning toward me, Family tension—I’ll tell you now. My husband passed away five years ago. You’re asking me, so as a friend I am telling you this. My mother-in-law was here, so.… The tension, like you said, happens to me sometimes, but for the children I try to adjust.

My overall impression was that something was profoundly wrong with Maya, and it all seemed to center on her in-laws. Maya had visible bruises on her forearms in the shape of fingerprints, but she laughed nervously, looked away, and said no when I asked in a hushed voice if she was being physically abused. The dark circles under her eyes hinted at tiredness or perhaps anemia; she reported little appetite and often had trouble getting up in the morning because she felt faint and had severe headaches. She said that she was tormented by guilt because her husband had died when she was away visiting her mother, so she was not with him at the time. The small household offered no sisters-in-law or other peer family members with whom Maya might have commiserated about this or any of her other troubles. There was also no one to share the household work, and Maya’s mother-in-law expected her to do it all.

Perhaps Maya’s relationship with her in-laws had never been particularly good; mothers- and daughters-in-law often conflict in North India’s patrilocal family system, where a young woman typically moves in with her husband and his parents after the wedding. The younger woman coming into the household is often expected to serve her mother-in-law and manage the household under her direction, and this can be difficult for both parties. Although she did not move in with them until after her first menstruation, Maya was married into the family at the age of seven.¹ Maya talked very little about the dynamics of her marital relationship, but her limited remarks suggested that the marriage had been reasonably happy. Her husband protected her and supported her financially, and together they had two children whom they both cherished.

Why did Maya now stay in this unpleasant and possibly abusive living situation? As a lower-middle-class woman, she had no education that would enable her to get a job. Her father had already died, and her own impoverished mother would be unable to support her and her two children if she moved out of her in-laws’ home. It would have been financially burdensome and socially inappropriate for her to return to her natal family, and typically women in her situation do not elect to live alone. Moreover, if she did so, she would likely lose any claim she might have to her husband’s inheritance. So she stayed and kept house for her in-laws—essentially bartering her labor for her children’s future security. Maya took charge of all the meal preparation and household cleaning, doing the tasks the way her mother-in-law expected. Although Maya cooked, her mother-in-law set the menu and did the shopping.

Given these responsibilities and household dynamics, Maya did very little to manage her health. Her two children did not know she had prediabetes, and she said she avoided telling people. Last time she went to her general doctor for a non-diabetes-related concern, she purposefully did not take with her the lab reports that diagnosed her as prediabetic because she was afraid that he might put her on insulin injections. She, like many women in my study, dreaded this possibility because she believed that insulin was habit-forming and did not like the idea of injecting herself. Maya said she went on a daily walk, but she was quick to clarify that she did this more to lift her mood than for her physical health.

When I visited her home that day, Maya was participating in the Hindu Navratri (nine-night) fast, during which she only consumed sweetened chai (tea), fruit, and milk by day, and a small dish of pumpkin with yogurt in the evening. This was not agreeing with her. The thing is, I’m feeling very weak these days. The dizziness I was telling you about, it’s been happening to me in between. I’m okay today, but the day before yesterday I was dizzy. Generally, junior women in the household perform fasts and religious observances on behalf of the family, so this might have been one reason why Maya persisted, despite the fact that her symptoms had worsened.

This book is about the lives of a group of women with type 2 diabetes—or sugar as they called it colloquially—who live in India’s capital, New Delhi. Most of the women with whom I worked were like Maya: they were situated somewhere in the nebulous contours of India’s urban middle class or lower middle class, were Hindu in their religious orientation, and did not work outside the home. Unlike Maya, most had a high school education or more and had been living with diabetes for a long time—eight years, on average. But there were quite a few who were still in the process of adjusting to a new diagnosis, and a few who were diagnosed only when I tested their blood sugar and found it abnormally high (for more details about the larger study sample, see Weaver et al. 2015 and Weaver and Hadley 2011).

I conducted the research for this book between 2009 and 2012, with a follow-up in 2016. In all, I worked with over 180 women with diabetes, but only a subgroup of women with whom I did in-depth ethnographic work appear in this book. I also worked with about 100 women without diabetes who appear primarily in chapter 4 as a comparison group in my discussion of mental health. Prior to the start of my formal research in 2009, I had spent time between 2001 and 2008 studying Hindi and working in North India. The contextual background that informed my research came from this period. Even the realization that type 2 diabetes was a major health concern came not from the design of a research itself, but from having lived and worked in India previously.

Type 2 diabetes is a chronic disease resulting from either a low level of insulin (a hormone secreted by the pancreas that regulates blood sugar) or from the body’s reduced response to the insulin secreted by the pancreas.² The condition impairs the body’s ability to process the carbohydrates contained in food. As a result, people with diabetes often have too much or too little sugar in their blood. Over time, organs receiving this blood become damaged, as does the circulatory system. This is one reason why diabetes is so serious: all of the body’s systems come into contact with blood, and therefore all of the body’s systems are at risk of damage from blood with abnormal sugar levels. The more frequently a person experiences abnormal sugar levels, the more quickly this damage occurs.

Despite advances in public awareness about diabetes in India and advances in technologies for its management over the last twenty years, managing blood sugar is a very complicated business. Blood sugar naturally fluctuates throughout each day, even in a person without diabetes. The goal of diabetes management is to keep blood sugar as stable as possible. For individuals with type 2 diabetes, this usually involves oral medications that lower blood sugar, and sometimes injected insulin to replace or augment the insulin normally produced by the pancreas. (People with type 1 diabetes must always inject insulin.) It also involves exercise and dietary changes that are intended to control body weight, limit intake of sugars and other carbohydrates that make blood sugar rise quickly, and help the body metabolize the carbohydrates that are ingested. A person with diabetes should check their blood sugar multiple times a day and make incremental adjustments to their medication dosage, food consumption, and activity to keep it as stable as possible. Even when a person with diabetes manages their blood sugar vigilantly, they sometimes experience abnormal levels, often too high (hyperglycemia), but sometimes too low (hypoglycemia). Likely, Maya’s headaches and weakness were symptoms of hypoglycemia she was experiencing during her fast, but I could not know for sure because she was not measuring her blood sugar, nor was she taking any medication for it. Unlike people with high blood pressure or high cholesterol, who can take their daily medication and go about their business, people with diabetes are never allowed to forget—even for an hour—that they have the disease.

Precise management of diabetes requires intensive and continuous self-care, and most women in my study, like Maya, did not do this. Studying how and why women made choices about prioritizing diabetes (or not) ended up teaching me all kinds of things about how women in this context order the broader priorities in their lives. I take as an analytic starting point the observation that in this cultural context, women like Maya are strongly socialized toward the care of others. This creates a paradox for the self-care demands of diabetes. Throughout the book, I examine questions such as: What do women in a situation like Maya’s do when they get diabetes? Whose well-being gets prioritized? What does care look like when women give it to their families, and when they enact it for themselves? What if self-care is not a relevant category at all for women like Maya?

Such questions about how women in North India negotiate self- and other-care are especially timely, given current public debates around women’s changing economic and social positions in the country, and about their rights and roles in public spaces. Just after this research took place, in 2012, the city of New Delhi acquired a central geographic and ideological position in these debates, when a twenty-three-year-old female physiotherapy intern known pseudonymously as Nirbhaya was brutally gang-raped and murdered on a moving off-duty public bus when she was out late one evening with a male friend. Indian law prohibits public media from reporting the names of rape victims because rape is highly stigmatizing. Nirbhaya means fearless in Hindi and was a moniker chosen specifically to restore dignity to the woman violated by this crime. Mohan Rao Bhagwat, the head of the conservative Hindu nationalist group Rashtriya Swayamsevak Sangh (RSS), publicly commented that such crimes hardly take place in ‘Bharat’ but occur frequently in ‘India’ (Times News Network 2013). By this he meant that sexual violence against women is not part of Bharat (the ancient Sanskrit word for India)—the traditional, principled, idyllic (and, notably, Hindu) nation—but rather is a product of the modern, corrupt India. Women’s provocative behavior—such as wearing supposedly titillating Western-style clothing, being out at night, or worse yet, being out at night with men who are not their relatives, as Nirbhaya was—is offered here as evidence of India’s moral disintegration.

Nirbhaya’s death, and the victim-blaming response to it from people like Bhagwat, led to massive protests against the government’s inability (or, some said, unwillingness) to provide adequate public safety for women and to respond appropriately to sexual violence. New Delhi was at the center of these protests, which eventually spread nationwide. Just before the Nirbhaya case, New Delhi had hosted its first Slut Walk, a protest march that was part of an ongoing transnational movement to end rape culture. But in 2014, another widely covered spate of sexual crimes against Delhi women involving five rapes in under twenty-four hours led newspapers to dub New Delhi India’s rape capital (Rukmini 2015).

At the core, these public discussions in urban India reflect broader discomfort with new versions of women’s gendered positions that straddle two very different visions of the nation. The Nirbhaya protests, and the accompanying media and lay discussions, questioned the prevailing idea that women can only be safe in India if they follow religious and socially conservative norms that keep them confined to the domestic sphere. Although none of the women with whom I worked were part of the Slut Walk (or anywhere near it, in fact, as this kind of activity was largely the purview of the liberal elite intelligentsia, who were not part of my research group), many women in my study also described feeling as if they were caught between the two Indias that Bhagwat so problematically referenced. For them, the conflict was less often about going out at night safely and more often about the degree to which they could or should maintain fidelity to domestic norms of service enshrined in ideas about Bharat. Women experienced internal conflict, as well as external criticism, if they were unable to uphold what was perceived to be the traditional woman’s responsibility of caring for others in the domestic sphere. Most of these women believed other-care activities to be of the utmost importance, and, like Maya during the Navratri fast, they went to great lengths to uphold them to whatever extent they could.

Given this rather fraught cultural context around women’s changing roles in urban Indian spaces, type 2 diabetes is a compelling way to think about gender, health, care, and modernity. Self-care has important gendered inflections all over the world, but perhaps especially in India, where cultural forms and ancient Vedic texts have historically emphasized an ideology of feminine virtue stemming directly from women’s domestic care of others. Diabetes is a point of entry for exploring larger questions about how women grapple with, adapt to, and modify the norms that orient them toward self-sacrifice. These questions mirror larger debates going on in India right now about how women ought to be acting as public citizens and domestic