Aurora Galache Montero
Farmacéutica titular de Ferreruela de Tábara. 49550 Zamora. (Spain).
Correspondence: Aurora Galache Montero. Calle Palencia, 2, 1D, 49022 Zamora (Spain).
Received 20 July 2008; modified 20 December 2008; accepted 3 February 2009
Steel Magnolias (1989) shows viewers the human side of illness. It places us in contact with the ability of certain people to carry on a normal life in the face of chronic illness and its negative repercussions on one’s health. The main character, who suffers from diabetes, tries to live a life without limitations in a constant battle against the barriers that her disease creates and always puts her happiness before the fatal consequences that her acts may give rise to.
Keywords: Type 1 Diabetes, Pre-gestational diabetes, Hypoglycaemia, Diabetic nephropathy, Kidney transplantation.
Títle: Steel Magnolias
Director: Herbert Ross
Music: Georges Delerue
Photography:John A. Alonzo
Film editing: Paul Hirsch
Screenplay: Robert Harling based on his play of the same name which deals with his experience of the death of his younger sister from diabetes.
Cast: Sally Field, Dolly Parton, Shirley Macline, Daryl Hansah, Olympia Dukakis, Julia Roberts, Tom Skerritt, Sam Shepard, Dylan McDermott, Kevin J. O'Connor, Bill McCutcheon, Ann Wedgeworth, Knowl Johnson, Jonathan Ward, Bibi Besch, Janina Turner y James Wlcek
Runtime: 119 min.
Genre: Drama, Comedy, Romance
Production Company:Rastar Films.
Synopsis: the everyday life of a group of women living in a small town in Virginia. The plot revolves around one of them, Shelby Eatenton, a young woman with diabetes who becomes pregnant after her wedding. Her disease worsens as a consequence of her pregnancy and she dies.
Awards: Nominated for an Academy Award in 1989 for Best Supporting Actress (Julia Roberts).
Cinema is very good at reflecting the circumstances and the individual and social context in which life takes place; it has been shown to be a perfect method to reveal illness both as an individual experience and as a social phenomenon1. Steel Magnolias (1989) by Herbert Ross shows us the humane and kind side of people in the face of illness, both of those who suffer it and of their family, friends and society in general.
The names of six actresses precede the title Steel Magnolias. Both details indicate that the film is going to tell a story about six women (magnolias) with a firm and unbreakable spirit (Figure 1), who have made a principle of their mutual friendship and who live in Chinquapin*, a village in Louisiana. Men play an anecdotic role and the names of the actors who play them actually appear in second place in the credits.
Shelby Eatenton Latcherie (Julia Roberts) is a diabetic young woman about to marry. The whole plot revolves around her and her illness. M’Lynn Eatenton (Sally Field), her mother, is very worried about her daughter’s condition. Truvy Jones (Dolly Parton) is the owner of the beauty parlour, a place that plays an essential part in the development of the plot (Figure 2). Annelle Dupuy Desoto (Daryl Hannah) is a young hairdresser who begins to work at the beauty parlour and whose husband, who is wanted by the police, has left her. Ouiser Boudreaux (Shirley MacLaine) is old, bad tempered and rich. Finally, Clairee Belcher (Olympia Dukakis) is also past her prime and has recently lost her husband.
The film begins on the day of Shelby’s wedding. While Truvy is doing her hair she suffers a hypoglycaemic attack (a descent of the blood sugar level) (Figure 3). This scene reveals that the main character is a sick person who suffers diabetes. Furthermore, by the reaction of her mother and friends it is clear that the affliction goes back a long way and is known by all. The wedding takes place and all the guests celebrate the event with great joy.
Shelby returns from her honeymoon at Christmas and shortly after tells her mother that she is pregnant. M’Lynn, who has always been protective of her daughter, constantly reminding her that she must take care of her health, is extremely upset by the news. She is perfectly conscious of the fact that pregnancy will be a great risk for Shelby. She reminds her that they could have adopted a child and Shelby tells her that they would not have been allowed to given her history, she also adds that she wants to have her own child. “I would rather have thirty minutes of wonderful than a lifetime of nothing special”. M’Lynn also displays a strong feeling of resentment towards the attitude of her son-in-law, Jackson Latcherie (Dylan McDermott).
The next part of the story begins with Jack’s (Daniel Camp, Shelby’s son) first birthday, which is celebrated by everyone with great happiness. This change in the time frame indicates that the birth took place without complications and that the child was born healthy.
Further on Shelby decides to change her look and goes to Truvy’s beauty parlour for it. She gets her long hair cut and her nails done. On pulling up one of her jumper sleeves her friend discovers an arm full of scars and bruises (Figure 4). Shelby tells her that since she gave birth she has had to undergo haemodialysis due to the worsening of her illness. She tells her friends that she is going to undergo an operation the following day, she is going to get a kidney transplant and her mother is the donor. They are admitted to hospital and everything seems to go perfectly well, her mother makes an excellent recovery and she seems to do the same. Shelby is very pleased, she feels strong, she leads the life she always has and looks after a son who makes her extremely happy.
One day after work Shelby returns home and starts to play with her son and when she takes him in her arms she begins to feel ill. She tries to phone her husband but she is not able to. When her husband returns he finds the child alone, weeping. He searches the house and finds Shelby unconscious on the floor. She is admitted to hospital and goes into a coma, her mother remains by her side, the time goes by and she does not wake up, the decision to withdraw life support is taken, and her mother is the only one who remains by her side when her death takes place, thus showing great courage. The rest of the family - her husband, her father and her two brothers - are not able to endure it and leave the room.
Straight away, M’Lynn, devastated, asks her son-in-law to fetch Shelby’s favourite dress, which is pink, her favourite colour, with cherries. At the funeral they bid farewell to her body with great love and admiration. Annelle, who is pregnant, says:” ...she (Shelby) just wanted to take care of that little baby and of you, of everybody she knew. And her poor little body was just worn out. It just wouldn’t let her do all the things she wanted to”. M’Lynn is shattered (Figure 5), Clairee, skillfully, tries to cheer her up and succeeds.
The film ends with the celebration of Easter Sunday, a holiday in the countryside during which many children scramble up a hillside looking for Easter eggs. Clairee takes young Jack in her arms and tells him the story of his mother and how special she was. During the party Annelle says that when her child is born she wants to name her Shelby, at that moment she goes into labour and they all go to hospital with her.
One Shelby dies, another Shelby is born. The death of a person who has always been sick and constantly struggling to live is set up against the birth of a new being whose uncertain future lies ahead.
In principle one must be reminded of the fact that in films everything is fiction, a close approach to reality, and this is the case with diabetes in Steel Magnolias..
Diabetes mellitus comprises a set of metabolic processes linked by faulty regulation of the blood glucose levels. Its impact has increased and it is currently an important health problem. It affects more and more children from an early age, and also adolescents. Its effects are significant in daily life and also in the long term. For M’Lynn it is clear that badly controlled diabetes is a serious clinical condition and several scenes capture the concern in her look when facing the progression of the illness in her daughter (Figure 6).
There are several types of diabetes mellitus, the most important and frequent ones are: type 1 diabetes mellitus, related to the failure of the pancreas to produce insulin and that mainly affects children and adolescents; type 2 diabetes mellitus, whose pathogeny involves a decrease of the insulin production and resistance of the tissue to its action especially affecting adults; and gestational diabetes mellitus.
Shelby suffers type 1 diabetes. She is young and her mother’s comments, attitude and behaviour during an episode of hypoglycaemia make it crystal clear that she has been suffering from it for a long time and that this is also known by her friends, who have learnt how to act. And to cap it all M’Lynn says: “She’s a diabetic. She just has a little too much insulin, that’s all”.
Diabetes involves various types of complications, some acute and some chronic, some of which are presented in Steel Magnolias..
One of the most serious acute complications is hypoglycaemia. The fall in blood sugar levels is shown at the beginning of the film when the main character is getting ready for her wedding at the beauty parlour. Shelby feels dizzy, she hears the people talking in the distance, she suffers cold sweat and confusion, signs which are effectively transmitted so that they can be perceived by the viewers and so that they can notice that there is something wrong with the protagonist. The symptoms are considerable, in spite of which the main character’s mother says: “This one was not bat at all. It was not bat at all”. With the onset of these symptoms her mother immediately gives her sweets (sugar) and some fruit juice (Figure 7) although she does not want to take them. This almost automatic behaviour has a purpose: her family and friends must be very well informed in order to act quickly when the aforementioned symptoms appear, and they are to consider this course of action as something natural. In that line M’Lynn says about her daughter: “Normality’s very important to Shelby”. Apart from the ones mentioned, there are other signs that indicate hypoglycaemia, such as restlessness, polyphagia, headache, memory loss, blurred vision or unjustified tiredness. M’Lynn attributes the event to the bustle of the wedding - excessive exercise is one of the causes - and perhaps to an imbalance in the insulin dosage (“She’s a diabetic. She just has a little too much insulin, that’s all”), but an episode of hypoglycaemia can also be due to poor dietary habits or alcohol consumption. Sometimes the reason is not clear.
Diabetic nephropathy is one of the chronic complications and it can lead to kidney failure. This manifests itself with vomiting, weakness, confusion and coma and can be fatal. It is obvious that Shelby suffers from diabetic nephropathy and the film makes this crystal clear. To avoid the worsening and to slow down the progression the doctors advise her against having children. Her mother says: “Dr. Mitchell told her on her last appointment children aren’t possible”. Pregnancy in a patient with her clinical history is usually very damaging. However, given the protagonist’s character she pays no attention. She often proves her strength in face of the illness, and the decision to become pregnant is one of these occasions since she puts her feelings before her health.
Everyone but her mother is happy about her new condition (Figure 5). M’Lynn is conscious of the fact that gestation can trigger a severe deterioration in her daughter’s fragile health. Her bleak premonition comes true, the diabetes becomes more serious and the nephropathy worsens leading to severe kidney failure. In order to survive, Shelby must undergo haemodialysis, with all the drawbacks this therapeutic measure entails.Two types of diabetes can appear during pregnancy, pregestational, which is Shelby’s case, and gestational. Both can lead to serious negative effects for the mother and the foetus.
Years ago doctors advised women with diabetic kidney disease against becoming pregnant since kidney function deteriorates with gestation. Survival levels have improved, but the chances that the mother will have normal eyesight and be free from renal replacement therapy as the child grows older are still low. The children of women with diabetic nephropathy are more likely to have serious malformations, probably due to poor glycaemic control in early pregnancy2.
In addition, severe kidney failure is related to a high risk of irreversible damage of the renal function, worsening of high blood pressure conditions, a high rate of underweight newborns and a high risk of premature births and abortions3.
Hyperglycaemia in the mother leads to foetal hyperglycaemia that affects organogenesis; this takes place during the first weeks of pregnancy. The incidence of congenital malformations is three to four times higher in the children of mothers with gestational and pregestational diabetes4. Currently, the rate of congenital malformations in the newborns of diabetic mothers varies from 0-5% in women with preconceptional control to 10% in women who are not subjected to preconceptional control. The risk of developing the illness is 5% higher in the children of diabetic mothers than in those of healthy mothers, and the prevalence is higher in people who suffer type 2 diabetes than in those who suffer type 1 diabetes. “There is talk about a greater possibility of diabetes mellitus and obesity in the newborns of unbalanced diabetic mothers, because of alterations in the Beta cells and in the adipocytes submitted to an altered metabolic environment during the first weeks of pregnancy”5.
In pregestational diabetes preconceptional control is the best way to prevent maternal and neonatal complications.
In the case of diabetic women with renal problems who wish to become pregnant a preconceptional control of sugar levels and blood pressure must be carried out, as well as an analytical control of the renal function, assessing microalbuminuria and proteinuria. They must be checked by a gynaecologist and an endocrinologist working together to monitor the metabolic alterations induced by pregnancy and to prevent the progression of the renal illness and foetal malformations. “Women who suffer nephropathy and high blood pressure are at higher risk of intrauterine foetal growth retardation”5.
In Steel Magnolias Shelby is lucky in giving birth to a healthy child who, in addition, remains healthy throughout the whole plot. Shelby herself had told her mother that “Diabetics have healthy babies all the time”; this was, therefore, her hope. However, it is not the case with her own health and she was conscious of the risk (“Sure, there may be risk involved [pregnancy], but that’s true for anybody”. After the birth of her child her illness deteriorates to such an extent that by the time her child is one she has to undergo a kidney transplant. In the face of such a situation Shelby states “I feel the need to make things as simple possible”. In the scene previously described, at Truvy’s beauty parlour, when she has just had a haircut she has a moment of weakness when expressing her concern, although she regains control right away. Her friend rolls up the left sleeve of her jumper and, astonished at what greets her eyes, asks what she has on her arms (Figure 4). Shelby says that her veins are in very poor condition because since the birth of her child she regularly undergoes dialysis since her pregnancy was very hard on her health and her kidneys have deteriorated badly.
In the film there are scenes that show the protagonist’s great strength before this new and serious situation that is her illness. She says that the scars left on her arm after dialysis are not painful. She always accepts adverse situations with normality, as if they were something usual in each person’s everyday life. The director manages to turn the particular situation of one person who suffers a terminal illness into a way of life, like the one that can be led by any healthy person. He always depicts an environment in which the social circle that revolves around the sick person, her family and friends, is involved
Shelby tells her friends that she has to undergo dialysis, but that it is nothing important. When she became pregnant the doctor told her that this would probably happen, but she went ahead even though she was aware of the future consequences when the progression of her illness would become accelerated.
Haemodialysis is a renal replacement therapy for patients with chronic terminal renal insufficiency. A high percentage of patients subjected to dialysis are diabetic, this illness being the origin of the renal damage. An aspect to bear in mind when carrying out the dialysis process on a chronic basis is the patients’ quality of life. It affects their everyday life, in its different dimensions, both in the physical one that includes mobility, moving from one place to another, and bodily care, and in the psycho-social one that includes social relationships, intellectual and emotional activity, communication, sleeping, resting, eating, leisure, work and household chores.
“Dialysis is an on and off therapy that is carried out 3 times a week during a period that varies between 3 and 5 hours, depending on the patient. This forces patients to important restrictions in their diets and in the intake of liquids during the time between treatments. Patients go to hospital 3 times a week to receive treatment, which creates both an objective and a psychological dependence on the artificial kidney in patients, thus limiting their social activities and their work. Dialysis only manages to replace the depurative activity of the kidneys, but not other functions such as immunity, secretion, the process of metabolizing or the excretion of hormones that control and take part in important activities such as erythropoiesis, bone metabolism, sexual activity and nutritional energy balance, which favours the appearance of complications which in the long term affect the patients’ health, influence their psychology negatively and deteriorate their social and home environment”6.
“The term quality of life is defined as the individual’s perception of his/her position in life within the cultural context and the system of values in which he/she lives and with regard to his/her goals, expectations, rules and concerns7. The concept is related to the individual’s level of satisfaction in the different spheres of life”6.
“Currently, the aim of renal replacement therapy is not only focused on extending life in terms of months or years, but on the real rehabilitation of the patient. This not only includes the employment level strictly speaking but also a more complex series of social, economic, psychological, emotional and cultural factors that take the definition of “quality of life” beyond merely clinical boundaries. A question that arises is that of how to measure the quality of life, either by means of objective or subjective elements that stem from the patient’s own perception”8.
The other alternative to haemodialysis is kidney transplant, which is also present in the film. Shelby tells her friends that she is going to undergo a kidney transplant operation in order to improve her quality of life and look after her child better. Her mother will be the donor of the organ. Her friends are rather worried about the news: Ouiser says something about death, unaware of the seriousness of her friend’s situation, for which she later feels guilty. The Eatentons spend the night before the operation together joking about the transplant. On the day of the operation Shelby’s family and friends wait for its outcome in the waiting room. According to the doctors “I think that despite everything, we have a very good result....Looks good. Looks real, real good”. Time goes by and one day, upon returning home, Shelby feels ill and later her husband finds her unconscious on the floor (Figure 8). At hospital the doctors tell the family she has suffered acute kidney rejection. Her condition is very serious; she is in a coma, possibly irreversible. M’Lynn remains constantly by her side; she does not leave her for a second (“What if she wakes up for two minutes and I’m not here?”), she repositions her, she speaks to her, she reads her magazines, she shows her pictures of her son… there is always room for hope (Figure 9). The days go by and she does not wake up so they decide that the best option is to disconnect the ventilator that keeps her alive. Her husband signs the documents.
Kidney transplants can be made from a dead donor or from a live donor; there are more chances of success when the kidney comes from a living relative who is histologically compatible with the patient to reduce the probabilities of rejection.
“One year after getting a kidney from a living relative, about 97% of people with diabetes are still alive. After 5 years, the number is approximately 83%. For people who get cadaver kidneys, about 93% are still alive after 1 year, and 75% are alive after 5 years”9.
The film always states the closeness that exists in Shelby’s home environment, an example of this being when the time comes to disconnect the ventilator and withdraw life support (Figures 10 and 11). All the family is present to bid her farewell, but at the very end only her mother remains, the rest cannot bear it and leave the room. Furthermore, her mother is the one who takes charge of the funeral arrangements (Figure 8). M’Lynn has always been represented as a brave mother, concerned with her daughter’s health and always encouraging her daughter to follow the doctors’ advice so that her life expectancy would be longer.
Steel Magnolias brings viewers closer to the world of patients with chronic pathologies. Shelby represents the feelings some of these patients might have, the will to live, the strength and the constant daily battle to overcome the obstacles posed by their illness. Julia Roberts played the role so well that she was nominated for an Oscar for Best Supporting Actress. She played the role of an apparently healthy character that always put her happiness before the consequences that could result from her actions. The protagonist dies due to a worsening of her illness that could have been prevented if she had followed the doctors’ orders that advised against pregnancy. The film also raises interesting questions from a bioethical point of view that are not analysed here. On the other hand, the film shows how the family and friends of a patient with a chronic illness should act, providing a warm and close environment as well as constant support and protection. This is how M’Lynn acts, always reminding her daughter that she must take care of herself and follow the doctors’ orders. She fights so that her daughter might live a longer life, but to live longer does not necessarily mean enjoying quality of life, which would imply the fulfilment of goals and expectations.
* Non-existent place, fictitious
Translation by the team of the Languages Service of the University of Salamanca.
Figure 1: Ouiser Boudreaux (Shirley MacLaine), Belcher (Olympia Dukakis), M'Lynn Eatenton (Sally Field), Shelby Eatenton Latcherie (Julia Roberts), Annelle Dupuy Desoto (Daryl Hannah) and Truvy Jones (Dolly Parton) are the protagonists of the film
Figure 2: Truvy’s beauty parlour, which plays an essential part in the development of the plot
Figure 3: During an episode of hypoglycaemia Shelby suffers cold sweat, dizziness and disorientation
Figure 4: Shelby displays scars and bruises on her arms due to haemodialysis
Figure 5: M'Lynn is devastated by her daughter’s death
Figure 6: Great concern can be read in M’Lynn’s face when her daughter tells her she is pregnant
Figure 7: In face of an episode of hypoglycaemia M’Lynn immediately gives Shelby sweets (sugar) and some fruit juice
Figure 8: Jackson finds his wife lying on the floor, unconscious
Figure 9: M'Lynn shows the comatose Shelby pictures of her son
Figure 10: The doctors disconnect the ventilator and…
Foto 11: Figure 11: …withdraw Shelby’s life support.