Twelve Days

I

On 11 January 1922, on a ward of the Toronto General Hospital, a boy of fourteen who weighed twenty-nine kilos was given fifteen cubic centimetres of a cloudy liquid, half in each buttock.

His name was Leonard Thompson and he had been in that bed since December. He had been on the starvation diet for two years, which was the only treatment available [seven hundred calories a day, sometimes less, so that the sugar would not kill him first]. It worked in the only way it could work. The children on that ward did not die of diabetes. They died of starvation, extremely thin, lucid to the end, their breath smelling of acetone [the mothers slept in chairs, in the corridor, in shifts].

The extract had been prepared for him by Banting and Best in a borrowed summer laboratory, with dogs, with ice and without a single chemist's hand on the team. It brought the blood sugar down a little and did not remove the ketone bodies. At the site of the injection he developed a sterile abscess.

In the clinical record what it was stayed written down, “no appreciable result”, in the small crooked hand of somebody writing standing up.

The first dose of insulin in history failed.

II

What happened next takes twelve days and is hardly ever told.

James Collip, a biochemist, shut himself away to purify the stuff with alcohol at different concentrations, precipitating and discarding, in a basement and in a hurry, while the boy stayed in bed. There were quarrels, there was a threat to patent it on his own account and there was a night when he nearly lost the procedure [he had not noted it down properly and had to reconstruct it from memory].

On 23 January they gave him Collip's extract. The blood glucose collapsed, the sugar in the urine almost disappeared and the ketones went. The boy lifted his head. On that day's sheet the note is different, “the patient appears brighter”, and with that the argument closed.

From those weeks comes the scene everybody repeats: the doctors going round the ward injecting one by one, and the children waking from their comas in order of bed, while the mothers who had spent weeks waiting for death saw their children open their eyes. It does not appear in the records of those weeks. Everything suggests it was assembled later, and there is no way of documenting it.

The founding image of this story has no source, and even so it has done all the publicity work of the century. A heroic account built on a scene nobody noted down and on an injection that failed.

Thompson lived thirteen more years; insulin never cured diabetes, it substitutes for it. He died of pneumonia in 1935, at twenty-seven.

In 1923, with the patent already in the university's hands, manufacture passed to a company in Indianapolis [the same one that half a century later would synthesise fluoxetine] which had what a university laboratory does not have, that is to say tanks, a cold chain and a distribution network, and the product reached the pharmacies within months. That is the part almost nobody disputes and that decided everything else. The discovery was academic and the insulin that reached bodies was industrial from the first year.

III

I have spent two weeks measuring my blood sugar for no medical reason.

The sensor is a white disc two and a half centimetres across that is fixed to the back of the arm with an applicator that makes a dry noise and does not hurt [an extremely fine filament stays inside, and that is never felt]. Sixty euros, fourteen days, I paid for it and nobody prescribed it. It is read by bringing the phone close, which is a silly and addictive gesture; you end up doing it in the lift, in the middle of a conversation, before sleeping.

Fasting, ninety-two. After two slices of white bread at ten past eight in the morning, a hundred and forty-seven at forty minutes and ninety again at an hour and a half. With a hangover, the liver does its own thing and the curve comes out odd all morning. Running slowly it does not come down. Running fast it goes up, which is the opposite of what I expected. On the eighth day it came off in the shower and I lost six hours of data [the adhesive does not hold up to steam, and the box does not say so].

None of that is of any use whatever to my body. Not one decision, not one adjustment, not one dose. I am healthy, or at least healthy enough for the word to serve. What I have bought for sixty euros is not health: it is the possibility of looking inwards, in real time, at a datum that a hundred years ago had to be got out of a child with a needle in the vein and a whole laboratory behind it.

Measuring yourself without needing to is a luxury, and that luxury has a pharmacy-offer price.

IV

She does need it, and she has worn it since she was nine.

The pump is the size of a large lighter and hooks onto the waistband or is taped to the hip —depending on the clothes and on the place it falls to that day—. The catheter goes into the abdomen and is changed every three days, always rotating the sites so that the tissue does not harden and goes on absorbing. Her belly is marked with small, paler dots, in a grid she has made over twenty years and knows by heart. She counts them under her breath when she chooses a place.

The first time we slept together she explained where I could put my weight and where I could not, with the same naturalness with which you say the bathroom door does not close properly. Then she disconnected the pump and left it on the bedside table, switched on, its loose cable hanging over the edge.

Forty minutes later the alarm went off. It was the sensor warning of a fall, and she reached towards the table without moving away entirely, looked at the number, said seventy-two and carried on. At twenty to four it sounded again, differently now, with the long tone that cannot be silenced, and then she did get up to fetch a carton of juice from the kitchen. She drank it standing, in the dark, in three swallows, looking at her phone.

She came back to bed with cold hands and fell asleep before I did. I lay looking at the ceiling with my phone face down on the table, next to her pump, both screens off and both measuring the same thing in different bodies.

In the morning I found the carton on the worktop and the receipt beside it, from another purchase, with the price of the box of sensors. In this country they are free to her and cost everybody else; in mine, the same sensor is sixty euros every fourteen days, and I pay for it to find out what white bread does to my blood. The difference between the two is not decided by the clinic. It is decided by the municipal register.

She said to me, while putting in the new catheter, a sentence I have had written down ever since: “the bad part is not the pricking; the bad part is that you cannot stop paying”.

V

The injection does not go into the vein. It goes under the skin, into a little fat where the liquid stays waiting, and there begins the first thing nobody tells: insulin does not travel loose. It travels in groups of six molecules huddled around a zinc atom, and huddled they do not fit through the capillary. You have to wait for the group to come apart, from six to two, from two to one. That takes between ten and forty minutes according to how warm the skin is, according to the place on the body and according to whether that leg has just climbed three flights of stairs.

That dismantling is the whole wait, and it is the reason for injecting before eating and not while eating. The analogues that came out in the nineties were designed for that and for nothing else: changing two pieces of the molecule so that the cluster comes apart sooner. A century of engineering to save fifteen minutes.

Once alone, it crosses into the blood. There it lasts little; four or five minutes, and half of it is taken by the liver on the first pass.

What it does on arriving is the strange part. It does not enter the cell. Not a single molecule of insulin enters any cell; it stays outside, on the surface of the muscle or the fat, and wedges into a piece that crosses the wall from side to side, with one half in the air and the other inside. On wedging in, the piece twists. The two inner halves, which until that moment were separate, touch and mark one another.

From there on the insulin has no part to play. The rest the cell does on its own, and it had it ready beforehand: inside there are bags loaded with doors already made, assembled and stored waiting for somebody to give the word. The bags rise to the surface, fuse with the wall and the doors are installed. Five to fifteen minutes.

Then the glucose goes in, having spent a while outside going round without knowing how to pass. It does not have to be pushed. It goes in on its own, downhill, because there is less inside than outside.

Insulin brings nothing. It says now, and each cell does what it already knew how to do. Muscle and fat open the doors; the liver, with the same signal on it, stops making sugar and sets to storing it. The same molecule gives opposite orders according to who reads it.

The end is a domestic scene. The piece with the insulin still stuck to it sinks inwards and comes apart. The cell eats the order [it obeys and destroys the paper].

None of this affects the brain, because its cells do not need anybody to open a door for them. That is why a fall is felt there first, and that is why there is no way of helping it from outside [the juice takes as long as it takes to arrive].

VI

The molecule is the same. Fifty-one amino acids, two chains, three disulphide bridges: the one made today in modified bacteria is better than that of 1922 because it drags no remains of cow pancreas with it, and it does the same as Collip's extract did. The chemistry was resolved a century ago and has not been the problem since.

What has been designed around it, on the other hand, is the charging.

Pumps that talk to sensors that talk to applications, consumables with expiry dates, catheters changed every three days, dosing algorithms updated by subscription, disposable pens, proprietary platforms that do not connect with the other manufacturer's. Each piece improves something real, and each piece adds a recurring payment. Thompson lacked purity. A body of now lacks continuity of payment, which is a new way of lacking insulin.

What became chronic was not the disease. It already was. It was the bill.

At the local pharmacy they explain it without drama, in the voice in which delivery times are explained: the sensor comes on prescription and the pump through another circuit; the consumables go separately and arrive on Tuesdays. Four suppliers, three deadlines and one counter [plus a complaints book nobody uses]. None of that existed in 1922, when the only thing needed was for the bottle not to be dirty.

VII

I live in a place where that is covered, and I have put on a sensor out of curiosity, like somebody buying an expensive set of scales. Getting indignant about another country's prices while measuring your blood sugar as a hobby is a comfortable literary genre and costs nothing.

And there is a second thing that obliges me to lower my voice, and it is the dollar.

The story is always told the same way. Three men sold the patent for a dollar each because it seemed indecent to them to charge for it. It is true and it is admirable. It is also true that that dollar prevented absolutely nothing. The university licensed the manufacture, industry scaled it, the following patents were placed on the analogues and the devices, and a century later the price did what it did. The cleanest founding gesture in the history of pharmacology had zero effect on the price, and had it for a hundred years running.

That is the uncomfortable part. It was not anybody in particular's greed; it was that a moral gesture with no instrument behind it holds nothing at all. A symbolic dollar is not a clause; a clause can be pleaded before a judge and a symbol cannot [there is the whole difference, and we learned it late].

VIII

The date celebrated is 11 January, and 11 January went wrong. What worked was the 23rd, and what was in between was not inspiration: it was twelve days of a chemist precipitating fractions in a basement, arguing with the others and nearly losing the method for not writing it down.

The credit went to the attempt, and not to the purification, which is the dull part, the one with a procedure and the one that can be repeated. Collip appears in the group photographs —third from the left, with the face of somebody thinking about something else— and almost never in the sentences.

The boy it was given to was not cured. He was given thirteen years and died at twenty-seven of a pneumonia, so that the first life saved by insulin lasted about as long as a long tenancy agreement.

There is still an abscess in that story. It is no longer in anybody's buttock.

The boy of 11 January received an impure thing that did not work, and twelve days later received the same thing clean and got up. Between the two injections the molecule did not change. What changed was what was around it, which is where the business has been from the beginning.

Banting, Best and Collip handed the patent over to the University of Toronto in 1923 for a dollar each.

In the United States, a vial of insulin has reached a cost of some three hundred dollars.

The sensor on my arm, sixty euros every fourteen days.