FOY, MARJORIE ELVIN, Ph.D. “Our Objective Wasn’t to Belittle People’s Behavior”: The History of Gestational Diabetes, 1921-1991. (2013) Directed by Charles Bolton. 298 pp. The emergence of the disease concept of Gestational Diabetes Mellitus during the late twentieth century was a product of collaborative efforts between physicians, medical researchers, businesses, and government agencies. This work is fundamentally an institutional history of medicine, situated in three specific genres within the field: disease creation studies, the examination of U.S. public health, and healthcare consumer history. This work traces changes in scientific and medical views, as well as the broader shift in how diseases are defined as that process moved out of the medical clinic and research lab into the halls of policy makers and government agencies. Scientific discovery and understanding emanated from the work of medical researchers, but the post-World War II era in the United States saw government agencies and healthcare businesses gain important roles in defining diseases and in creating consumer identities for patients. This was especially visible with gestational diabetes because many of the women who made up the rising numbers of new cases in the second half of the twentieth century came from lower-income groups who accessed their healthcare through government-subsidized programs like Medicaid. Through a range of historical sources, I examine the development of this dynamic relationship between medical knowledge and practice; business ideologies and approaches in an expanding healthcare market; and government policy on healthcare. “OUR OBJECTIVE WASN’T TO BELITTLE PEOPLE’S BEHAVIOR” THE HISTORY OF GESTATIONAL DIABETES, 1921-1991 by Marjorie Elvin Foy A Dissertation Submitted to the Faculty of the Graduate School at The University of North Carolina at Greensboro in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Greensboro 2013 Approved by Dr. Charles Bolton Committee Chair © 2013 Marjorie Elvin Foy To Bob, for everything. ii APPROVAL PAGE This dissertation has been approved by the following committee of the Faculty of The Graduate School at The University of North Carolina at Greensboro. Committee Chair _________________________________________ Charles Bolton Committee Members _________________________________________ Cheryl Logan _________________________________________ Warren G. O’Brien _________________________________________ Jeff Jones ____________________________ Date of Acceptance by Committee _________________________ Date of Final Oral Examination iii ACKNOWLEDGEMENTS There is not sufficient room to acknowledge everyone who has helped me with this project. My committee chair, Chuck Bolton, invested his time and energy in helping me bring this project to fruition and to see the bigger picture in this history. My committee members have all guided me in important ways as well. Cheryl Logan pushed me to understand the context of scientific ideas, and spent long hours discussing my work. Greg O’Brien, in his very pragmatic style, has made me learn to verbalize my ideas clearly and concisely – a skill that will serve me well. Jeff Jones has always stressed that my work as a historian should be connected to my ideas on teaching. I would also like to thank Arlene Tuchman who introduced me to the topic and very patiently listened to my early musings on the subject. Boyd Metzger, who is actually an important piece of this history, encouraged me in my research and offered me his office space, his time, and his belief in me. I appreciate the help and support of my colleagues, family, and friends as well. I received important financial support for this research. I received the Lisbeth Stevens Graduate Scholarship for the 2007-2008 academic year. I am thankful for the very generous Scholar-Athlete Fellowship that LifeScan, a Johnson & Johnson Company, created for me during the 2008 and 2009 calendar years. In 2009-2010, I was fortunate to receive the Allen Trelease Graduate Fellowship in History. I was also honored to receive a Schlesinger Library Dissertation Fellowship from Harvard University for the 2009- 2010 academic year. iv TABLE OF CONTENTS Page LIST OF TABLES ............................................................................................................ vii LIST OF FIGURES ......................................................................................................... viii CHAPTER I. INTRODUCTION .................................................................................................1 Part I: Diabetic Identity in the Twentieth Century.....................................12 Part II: Making Gestational Diabetes .........................................................16 II. PART I: DIABETIC IDENTITY IN THE TWENTIETH CENTURY ..............20 III. “IT IS TRULY MIRACULOUS”: INSULIN AND THE TRANSFORMATION OF DIABETES ...........................................................24 The Long Road to “Discovery” .................................................................28 Diabetes in the 1920s .................................................................................36 From Discovery to Market .........................................................................48 Conclusion .................................................................................................65 IV. “I HAD TO LEARN HOW TO TAKE CARE OF THEM”: PRISCILLA WHITE AND DIABETIC PREGNANCY ..................................67 Pregnancy and the Gendering of Diabetes .................................................71 Deterring Diabetic Pregnancy ....................................................................83 Enter Priscilla White ..................................................................................94 Evaluating Risk: The White Classification System .................................104 Conclusion ...............................................................................................112 V. ONLY WHEN PREGNANT .............................................................................117 Reframing Glycosuria of Pregnancy ........................................................121 Glycosuria of Pregnancy or Pre-diabetes? ...............................................128 Glycosuria of Pregnancy and the Baby ....................................................140 One or Two Patients in Pre-diabetes of Pregnancy? ................................148 Conclusion ...............................................................................................154 VI. PART II: MAKING GESTATIONAL DIABETES ..........................................157 v VII. MEDICAL RESEARCH, DIABETIC PREGNANCY, AND DEFINING GESTATIONAL DIABETES ..................................................162 Building a Research Career .....................................................................169 The Diabetes in Pregnancy Center at Northwestern University ..............176 The National Diabetes Research and Education Act ...............................186 The First International Workshop-Conference on Gestational Diabetes Mellitus .............................................................196 Conclusion ...............................................................................................200 VIII. GESTATIONAL DIABETES MELLITUS: MEDICINE, CULTURE, POLICY, AND BUSINESS .....................................................203 Diagnosing Gestational Diabetes .............................................................210 Screening for Gestational Diabetes ..........................................................218 Gestational Diabetes and Medicaid .........................................................227 The Second Workshop on GDM..............................................................238 Conclusion ...............................................................................................245 IX. EPILOGUE ........................................................................................................252 BIBLIOGRAPHY ............................................................................................................257 vi LIST OF TABLES Page Table 1. The original White Classification System adapted from her 1949 article .......................................................................108 Table 2. Summary of Medicaid policies and GDM guidelines, 1980 to 1986 .....................................................................236 vii LIST OF FIGURES Page Figure 1. Before and after photos of insulin patient ..........................................................45 Figure 2. Pamphlet, Prenatal Care, Children’s Bureau ......................................................87 Figure 3. Pregnancies in Diabetes Mellitus, Joslin Clinic, 1898-1977 ..............................97 Figure 4. White’s notes on the metabolic impact of pregnancy ......................................102 Figure 5. Chart of blood sugar measurements .................................................................133 Figure 6. Section 1 of the National Diabetes Mellitus Research and Education Act, PL 93-354, signed into law on July 23, 1974 ........................................191 viii CHAPTER I INTRODUCTION This dissertation investigates how the diagnosis of Gestational Diabetes Mellitus (GDM) was created during the twentieth century through the collaborative efforts of physicians, medical researchers, businesses, and government agencies. It traces the changes in scientific and medical