Sweet Mayhem


By Spencer Nadler

April 2, 2003


Gary Hall is tired all the time now, but since he swims for hours each day at the Phoenix Swim Club, he ascribes his fatigue to his workouts. His episodic shakes in the pool he imputes to the burning of too many calories, so when they strike he leaves the water to have something to eat. His thirst seems unquenchable, but Phoenix is a desert city; surely more fluid replacement is needed here, especially if you are a 1996 Olympic medalist training to qualify for the 2000 Olympics. Gary buys eight gallons of orange juice at the grocery one day, and as soon as he gets home quaffs almost two of them. It is March 1999. He is twenty-four years old.

His father, Gary Hall, Sr., was himself an Olympic swimmer (in 1968, 1972, and 1976). He is now an ophthalmologist. When his son develops blurry vision, he schedules an eye examination. But Gary never gets there; a week before his appointment, he collapses at a party. The family doctor discovers that Gary’s blood-sugar level is over 300 milligrams per deciliter (the normal range is 60 to 115). He has diabetes. A Phoenix endocrinologist confirms the diagnosis. Seemingly in a hurry to see other patients or be done with his harried day, he utters the words “Type 1, insulin-dependent diabetes” and informs Gary that he will require daily insulin injections to keep himself alive, that he will never again be an Olympian, and that his swimming career is over. One has to wonder if, despite his years of practice, this physician really grasps the personal ramifications of Type 1 diabetes. Gary distinctly remembers his own sigh of defeat. How could sugar so thoroughly sour his life?

The pancreas is a lobulated, dingo-colored organ about the size and shape of an Australian pygmy possum; it, too, has a head, neck, body, and tail. Tucked into the back-upper abdomen, shrouded by portions of bowel, liver, stomach, and spleen, it can have maladies that are difficult to detect. Under the microscope, the pancreas is a profusion of closely packed, cobalt-violet glands that extrude their enzyme-rich, alkaline fluid through pervasive ductal byways into the small bowel; here, this liquid neutralizes and digests acidic food entering from the stomach. Digestion couldn’t function without it. The pancreas has yet another critical purpose: scattered throughout are clusters of uniform, pale cells—the islets of Langerhans. Each variety of islet cell secretes its singular hormone directly into the blood, and the commonest type—the beta cell—secretes insulin. It is autoimmunity—the selective destruction of beta cells by the body’s own immune system—that causes Type 1 diabetes, requiring insulin supplementation from without. Such autoimmunity is likely triggered by a chemical toxin, virus, or dietary element that is impossible to identify or prevent. It begins most commonly in childhood or early adolescence. (Type 2 diabetes is a resistance to modest decreases in insulin; it often does not present itself until later in life, and its treatment may not require insulin.)

Insulin both galvanizes and regulates the uptake of blood sugar into body cells. This absorption fuels the liver, muscles, and brain. Insulin also boosts and tempers the storage of fat—an additional fuel. Without insulin, blood sugar gathers outside body cells and the blood-sugar level rises until it causes sweet mayhem. Rapidly occurring high blood sugar (hyperglycemia) begets body resistance to insulin; this decreases sugar uptake, causing fatigue, thirst, excessive urination, blurry vision, dry skin, infection, irritability, and diminished alertness. If rapid-onset hyperglycemia goes untreated, electrolyte imbalance can follow, and death. But let the blood-sugar level rise less rapidly and remain chronically high, and the result is permanent damage to the blood vessels, eyes, kidneys, and nerves. Undertreated, long-term hyperglycemia can also maim, and slowly kill.

If the blood-sugar level gets too low (hypoglycemia), a different set of signs and symptoms prevails—trembling, lightheadedness, rapid or pounding heart-beat, and poor coordination. Seizures, coma, and death can ensue. Mood swings and emotional lability often precede all other symptoms, and mental confusion can prevent a diabetic from recognizing his own hypoglycemia.

Managing Type 1 diabetes is a metabolic balancing act that attempts to keep the blood-sugar level normal, a careful imitation of what beta cells do involuntarily for nondiabetics. Skirting diabetic complications requires a constantly demanding treatment and a highly motivated patient.

Since insulin is a protein, it cannot be taken in pill form; digestion breaks it down. It is injected beneath the skin into bibulous subcutaneous fat—often in the stomach, thighs, and buttocks—and people with little body fat, like athletes and children, can experience distracting, injection-associated pain. In addition, the Type 1 diabetic must stick his fingers for droplets of blood to ascertain his blood-sugar levels. Finger needling is the most painful element in Type 1 treatment, but it is essential. Frequent monitoring of blood-sugar levels allows for tighter diabetic control, a simulation of normality. Blood-sugar levels mostly reflect the carbohydrates (starches) in the foods we eat—cereals, pasta, breads, fruit juices. Counting the daily carbohydrate intake is, like the monitoring of blood sugar, another way to gauge the body’s insulin requirements. Learning about nutrition and the effect that different foods have on his blood-sugar level allows a diabetic greater flexibility of food choices in his dietary plans.

Anne Peters is an associate professor of medicine and director of the Clinical Diabetes Program at UCLA. Six weeks after his diagnosis, Gary Hall and his girlfriend, Elizabeth Peterson, fly in from Phoenix to consult with her. Plane-delayed, they arrive at Anne’s office two hours late. She packs them into her red VW bug and, along with one of her endocrinology fellows, heads across town to Panorama City, where she is scheduled to lecture to a physicians’ group on the nuances of diabetic therapy. En route with her new six-foot-six-inch patient beside her, Anne conducts her initial interview. She peppers Gary with questions about his significant interests, his training habits, his ambitions, his knowledge of diabetes. She learns that he is already giving himself insulin injections up to eight times each day; though he uses an “insulin pen” with short, tiny-bore needles, the pen pricks still feel like self-flagellations. By the day’s end—Anne spends six hours with him—Gary begins to talk about competing in the Sydney Olympics despite his illness. Knowing then that she has met a special patient, Anne tells Gary that she believes he can continue to swim competitively. This medical testament gives Gary his life back.

A month later, aware that new patients often do not know when or how to ask for help, Anne decides to visit Gary at the University of California Berkeley campus, where he is training with the UC swim coach, Mike Bottom. Mike has a passion for the proper training of sprinters. An Olympic sprinter himself in 1980, the year Russia invaded Afghanistan and President Carter decreed a boycott of the Moscow Olympic games, he was prevented by international politics from competing in a single Olympic event. While getting his master’s in counseling psychology at Auburn, Mike developed a program for sprint swimmers. His coaching philosophy and techniques are predicated on the fact that sprinters have traditionally trained with distance swimmers, thus failing to get the specific preparation they need. Distance swimmers thrive by improving their whole-body endurance while undertaking moderate-intensity intervals to recruit the slow-twitch muscle fibers used to swim at a comparatively slow pace. Mike trains sprinters with high-intensity intervals at close to actual race speed to recruit the fast-twitch muscle fibers used in sprinting.

Anne knows virtually nothing about Olympic sprint-training and cannot properly collaborate with Gary without familiarizing herself with the absolute outlay of energy required by an Olympic-caliber 50-meter sprinter. She also wants to meet Mike and give him a sense of what to expect from Type 1 illness; he must be capable of spotting the onset of hypoglycemia during a workout, making sure that Gary leaves the pool and eats some sugary fare.

At poolside, Anne is awed by Gary’s formidable size and muscularity, his speed and harmony in the water. She notes that the other swimmers, as muscled and rangy as he, do not seem to split the water with the same perfect sensuousness. Perhaps it is the biotechnical precision of his stroke that makes it look so easy.

In the course of the afternoon, Anne discovers that Mike has a detailed, coach’s knowledge of nutrition and fuel metabolism and is receptive to learning more about these subjects from a diabetologist’s perspective. Anne emphasizes the importance of food supplements, ones that would keep Gary’s blood sugars as even as possible despite the fiercest consumption of his energy.

Gary and Mike have already settled on a supplement. Doug Herthel, a veterinarian in Santa Ynez, California, developed a dietary supplement for horses, and after one of his patients, Fusaichi Pegasus, won the Kentucky Derby, he adapted it for human use and named it Platinum Performance. Mike, always looking for ways to improve swimming efficacy, introduced it to some of his Cal-Berkeley team members and found it to be the most effective performance-enhancing supplement he had tried. Ultimately, Gary found that Platinum Performance not only boosted his swimming capabilities but kept his blood sugars from precipitously falling or spiking. Along with Muscle Milk (a protein shake), Platinum Performance has become an important component of Gary’s daily diabetic and training diet. Mike gives Anne all the particulars and puts her in touch with Doug Herthel. Ultimately, all agree that Platinum Performance is the ideal food supplement for Gary.

Exercise increases the sensitivity of body cells to insulin; it boosts insulin’s potency. Hence a 100-point plunge in Gary’s blood-sugar level can occur during his workout and tip him into perilous hypoglycemia. There is a window of 30 to 120 minutes after a workout when the muscles take in as much sugar as possible and store it as glycogen for the next energy expenditure; it is during these ninety minutes that Gary has to inject himself with a rapid-acting insulin and carbohydrate-load with Gatorade.

In the 1890s the German physiologist Oskar Minkowski demonstrated that the pancreas contained an anti-diabetic substance. In 1901 a Johns Hopkins pathologist, Eugene Opie, discovered that this substance was produced by the beta cells of the islets of Langerhans. What followed was a race to extract this substance, purify it, and make possible the treatment of dying diabetic children. Frederick Banting, Charles Best, James Collip, and John MacLeod are credited with the discovery of this purified extract—insulin—in Toronto, in 1921. Before this breakthrough, people with Type 1 diabetes had to make do with exercise and a low-carbohydrate, semi-starvation diet. Within a year of their diagnosis, most Type 1s were dead. Elizabeth Hughes, a fourteen-year-old girl who weighed a mere fifty-two pounds, was one of the first Type 1s to receive “Banting’s extract” at the Toronto General Hospital, and she flourished on it. After several months, she had gained fifty-seven pounds. She lived into her seventies.

In 1923, Banting and MacLeod were awarded the Nobel Prize in medicine for their extraction of insulin. They divided the prize money with Best and Collip.

In the spring of 2000, after school is out, Mike Bottom arrives in Phoenix with a bevy of sprinters to train in earnest for the national Olympic trials in Indianapolis in August. Those who qualify will move on to the September Olympics in Sydney. The Phoenix Swim Club, cofounded by Gary Hall, Sr., has all the accoutrements of an Olympic training center—an Olympic-sized pool, a sports psychologist, and dry-land workout facilities, complete with trainers and physical therapists. Along with Gary, the gathering includes Jon Olson, Anthony Ervin, Scott Greenwood, and Matt Macedo from the United States; Francisco Sanchez from Venezuela; Bart Kizierowski from Poland; and Julio Santos and Felipe Delgado from Ecuador. All are world-class sprinters, some established, others with prodigious potential and dreams of Olympic glory. Gordon Kozulj, from Croatia, is also there. He is not a sprinter, not even a freestyler; he is a 200-meter backstroke Olympian training amidst a covey of fast guns.

They abide two-a-day workouts, five to seven hours, mixing long, slow swims with high-intensity sprints and dry-land weight lifting, running, jumping, and speed-bag punching—a curiosity that Mike has set up to improve hand-eye coordination. They push one another beyond endurance, stretching the aquatic envelope, and a camaraderie of warriors soon develops, even though they all know that only forty-eight swimmers will be chosen from the thirteen hundred competitors at the trials.

The speed-bag workout becomes the group favorite. Before they started training in Phoenix, none of the swimmers had ever hardened with a punching bag; now they all have bloody hands from it. “If you can’t beat ’em in the pool, beat ’em in the parking lot,” Gary says.

Anne Peters joins Gary at the Olympic trials in Indianapolis. By this time she has assimilated enough about sprinting to complement Gary’s competitive efforts. She knows that he cannot do on trial days what he most needs to do for his health—maintain his blood-sugar control. Sprinters get intensely nervous before big races; they vomit and often cannot eat or sleep. At Gary’s side, Anne gently emphasizes the need for appropriate food and supplements before each race, to elevate his blood sugars slightly as a means of preventing post-race hypoglycemia. She urges him to load up diligently with rapid-acting insulin and sugar drinks after each race. On days when high anxiety prevents Gary from eating, Anne encourages sugar-containing fluids, which he drinks until his blood-sugar level is acceptable.

As the level of competition increases, Gary dwells more and more within himself, a cocooning that keeps the the outside world—including the frenzied media—at bay. He wears his headset for hours on end, quieting his thoughts with music. His final approach is all about inner strength—a self-control that builds a winner’s sense of independence and insuperability.

The 100-meter freestyle event precedes the 50. If Gary swims poorly in the 100 prelims or tires before the semis, he will withdraw to concentrate on the 50. Standing on the prelim starting block, he is acutely aware that he has not competed in a major 100-meter freestyle race since the 1998 spring nationals. He is confounded by the simultaneous experience of his racer’s sense of invincibility and his diabetic’s sense of mortality.

In both the prelims and semis, Gary qualifies second behind Neil Walker. In the finals, Gary appears on the block in the red, white, and blue “Rocky” shorts he has kept from a Muhammad Ali fundraiser for Parkinson’s disease. An American flag adorns his swim cap. He flexes his biceps when introduced, playing to the sellout crowd at the Indianapolis University natatorium. Then he swims a 48.84 behind Neil Walker’s 48.71, and both qualify for the two Olympic 100-meter freestyle berths. This categorical success occurs little more than a year after Gary’s diabetes diagnosis.

Despite his success in the 100, Gary’s passion is the 50. He has always been better suited to it. Since the energy expenditure in the 50 is more intensively focused, the margin of blood-sugar-regulation error is diminished. Gary does not disappoint. He leads all sixteen 50-meter swimmers in the qualifying round, with 21.93, just .3 seconds slower than the world record set by Alexander Popov, his Russian nemesis. (They had trash-talked in Atlanta in 1996, where Popov beat Gary for the gold in both the 100 and the 50 by the slimmest of margins.)

In the 50-meter semifinals, Gary assails his lane: 21.91, just .01 seconds ahead of fellow Phoenix Swim Clubber Anthony Ervin. The two join an elite brotherhood that includes Matt Biondi, Tom Jager, and Alexander Popov; these five are the only men who have broken the 22-second, 50-meter freestyle barrier.

In the evening final, once again decked out in his “Rocky” shorts and flexing his biceps when introduced, Gary improves his performance—21.76 seconds. This breaks Tom Jager’s ten-year record of 21.81. A smidgen behind is Anthony Ervin; he also breaks this record, at 21. 80. They will be the U.S. Olympic hopefuls in the 50 freestyle. Popov must now take note; Gary will be in Australia to alchemize Atlanta silver into Sydney gold.

In the past, a patient with diabetes was told that he could not eat any sugar at all. He was placed on the very strict, carbohydrate-rigid, American Diabetes Association diabetic diet. As a result, children with diabetes felt isolated from other kids; they could not eat cake or ice cream or candy as others did, could not fit in at parties. Many of these children subsequently developed eating disorders. Too much had been made of their food habits. Today, the diabetic diet is changing: All carbohydrates are being treated in essentially the same way; it has been shown that an equivalent amount of chocolate cake can be substituted for baked potato with no untoward effects. A Type 1 can and should eat anything he wants, provided his carbohydrate intake is always counted (usually in grams) and properly covered by insulin. He administers an amount of insulin that is based on the gram total of carbohydrate he consumes, not the particular kind. Anne  Peters learns what each new Type 1 patient likes to eat, and mirrors his eating habits with suitable types and quantities of insulin. The usual ratio is one unit of Humalog or Novolog (rapid-acting insulin) for fifteen grams of carbohydrate (one slice of bread). Patients with Type 1 diabetes must learn to count about-to-be-consumed carbohydrates in grams before each meal (or consumed carbohydrates after each meal) and give themselves insulin based on the one/fifteen ratio.

Gary uses two types of insulin: He takes his intermediate-acting, NPH insulin each morning and each night; it provides a basal insulin flow and, importantly, covers sugar creation by the liver, especially at night. He takes his rapid-acting Humalog insulin with meals to offset the carbohydrate consumption, and also after each aquatic sprint, with ample sugar drinks to maximize carbohydrate loading and prevent muscle-glycogen depletion in the ensuing race.

The Sydney Olympics of September 2000 would now be a distant memory for me were it not for two swimming events; they remain with me not for all that they demonstrated but for all that was left unprobed and misinterpreted.

I arrived in Sydney on the evening of September 14, a day and a half before the swimming events began. Anne Peters, to whom I had been introduced by a colleague, had urged me to come to Sydney to see Gary swim and to write his story. She arranged for my tickets to swimming events that had been sold out for months. In the morning, from my bed-and-breakfast vantage, Sydney enveloped me like a kangaroo’s pouch; it is a physical fusion of Seattle and San Francisco, though the climate is more like San Diego’s. I walked the crowded streets in the shade of skyscrapers, where sun-bronzed Australians sauntered. An Olympic charge was in the air. At the Port Jackson (Sydney Harbour) foreshore, I strolled through the Royal Botanic Gardens behind the Opera House to get a horticultural sense of “down under.” I saw fig trees the size of buildings and giant eucalyptuses, their canopies inhabited by upside-down-hanging flying foxes, asleep in the sun. Hefty white cockatoos ensconced in the highest branches shrieked in imitation of the city’s uncounted sounds. Sacred ibis walked the grounds, their heads black, their bodies white, elegantly scrounging for human food. Patches of waratahs (the state flower of New South Wales), as scarlet as Paneth cell granules, punctuated the gardens. From the stairs of the Opera House—its multifaceted, tiled roof billowed like sails—I could see Sydney Harbour Bridge and the meandering spread of Port Jackson.

I ate good storefront sushi, bought the local papers, and, as the sun set, returned to my room. Anne was with Elizabeth and the Hall family aboard the cruise liner occupied by CNN and Sports Illustrated: it was docked in the Sydney harbor. Gary and Mike were in the Olympic village. I talked with Anne on the telephone; Gary had developed an acute sinusitis. Infections increase insulin resistance, making it harder to load carbohydrates properly.

That evening, I lay on my bed thinking about Gary’s Type 1 pancreas. At his abdominal floor, devoid of its beta cells, his pancreas sat as listless as a sunken submarine, unable to control vital carbohydrate functions. Gary’s fate seemed ironic and lamentable to me then. I glanced at the newspaper sports sections and saw that Gary was the center of a media maelstrom. “We will smash the Australians like guitars,” he had written in his August 22 CNNSI. com diary. I read the passage from a copy I had in my notes:

Anyone familiar with the sport of swimming knows that Australia is a contender. The popularity of swimming draws the country’s greatest athletes. The incentives offered to a swimmer are enough to retire on. The athletes are treated as professionals, and have the respect of society and government, which subsidizes AUS$120 million (about US$80 million) a year to the swim program. The program that the country has to offer should be the example for other national governing bodies to follow. And if it’s possible to wish Australia well without getting squashed in the process, I do. I hope that they do well. I feel that it may be exactly what United States swimming needs. . . .

I like Australia, in truth. I like Australians. The country is beautiful, and the people are admirable. Good humor and genuine kindness seem a predominant characteristic. My biased opinion says that we will smash them like guitars. Historically the U.S. has always risen to the occasion. But the logic in that remote area of my brain says it won’t be so easy for the United States to dominate the waters this time. Whatever the results, the world will witness great swimming.

We will smash them like guitars. This was the single phrase the Australian media had lifted out of context and splashed across their newspapers like Tasman Sea saltwater, ignoring the respect with which Gary had otherwise addressed Australia and its swimmers. But this was the media, after all, not the Australian conscience.

The Olympic swimming events began on September 16, two days after I arrived. In the morning I went to the Sydney International Aquatic Center, at Homebush Bay. From without, the center was not particularly distinguishable from adjacent, giant-domed Olympic-complex buildings. Once inside, I beheld its spectacular functional scope. A 10-lane, 50-by-25-meter Olympic competition pool was coupled with a 33-by-25-meter utility pool for diving, water polo, and synchronized swimming. The building was covered by a wide-span roof with column-free spectator views. The problem was that more than 15,000 seats surrounded the pools; unless you sat in the closest rows, the sprinters looked like thrashing platypuses.

The men’s 4-by-100-meter freestyle relay finals were in the evening. Without a ticket, I watched it on Australian TV. The U.S. had never been beaten in this event, but the Australians were preparing to mount a formidable charge. Although Brazil, Germany, Italy, Sweden, and France were also represented, it was, in effect, a two-country race. Michael Klim, an Australian champion, swam the first 100 in a world-record-breaking 48.18. Anthony Ervin, the U.S. incipient 50-meter star, was second in 48.89. Neil Walker, swimming the second 100 meters, made up .17 seconds on Australia’s Chris Fydler. American Jason Lezak tightened the race by gaining .29 seconds on Australian Ashley Callus. Now it was all up to Gary, who swam the anchor 100 against the precocious Ian Thorpe. Gary bested him by .06 seconds, but that was not enough to overcome the Australians’ cumulative .25-second lead. Though both teams broke the world record, the television cameras zeroed in on the Australians. They were hugging one another, bouncing happily on their starting block. Klim pantomimed a guitar strummer and others followed suit, attracting every television camera in the vicinity. Finally Gary ambled into the picture to congratulate the Aussies. The TV announcer complimented him on his gentlemanliness, and a cameraman, as if with a touch of embarrassment, briefly moved his focus to the American starting block.

None of this seemed important. It was Gary’s diabetes that held me. With only 10 meters to go in this race, he had made up Thorpe’s head start; in fact, he was slightly ahead. Surprisingly (Thorpe usually does his magic in the longer races), Gary let his lead slip, didn’t have a final spurt. The TV announcers gave Thorpe credit for a mighty last-ditch effort, but I believed Gary’s illness was to blame.

I got to Anne as soon as I could. She, too, had observed Gary’s apparent petering out and believed that his sinus infection had left him glycogen-depleted. He had cleared himself of his infection only the day before this race, and it takes three days to glycogen-load to one’s maximum. But Gary had won many times before despite metabolic imperfection. If he had run on adrenaline instead of glycogen at the end of this tightest race, could he have achieved the same efficiency? Anne could not say; what she did know was that Gary never excused a performance on the basis of health.

But it was the 50-meter freestyle that Gary had come to swim, and I will never forget what happened in the finals of that event.

My best ticket was for that race. I was only forty rows back, center-pool, surrounded by the charming Dutch in their orange-plastic windmill hats. They were cheering for Pieter van den Hoogenband. He had already won gold in the 200- and 100-meter freestyle events. The 50-meter finalists, many of them icons, marched onto the competition pool deck. As the fastest qualifier, Gary would swim in lane four. He was smiling confidently. The Hall family sat with Anne and Elizabeth in the first row. Mike was crouched on the pool deck.

Could Gary take the gold in this shortest freestyle, encumbered by his diabetes and his controversial celebrity? The din dwindled to complete silence while the starter shouted “Take your marks” and then “Go.” But as Gary dived off the block, before he hit the water, he heard the ritualistic clamor explode again. In an instant, he was submerged in the eerie quiet of water; not invigorating, not seductive, it was merely a vehicle for speed. An aquamarine froth gathered about the swimmers as they moved, all at approximately the same pace. Soon Gary’s head rose into the glittering chlorinated air, which reverberated with guttural cries. Gary sensed the swimmers on either side of him. Anthony had executed the best start of his life. He is usually .4 seconds behind Gary after the start; today, he was ahead. From that point on, Gary pulled, kicked, reached, and pushed with controlled, almost automatic explosiveness. There was no holding back, no time to think. As he approached the wall, he looked to the pool floor, to the “T” marker: he was 1.5 meters from the end. To get this far, he had overcome every trial of his illness, every athletic and social challenge. On his final stroke, he rolled on his side; this allowed him the greatest possible extension for the touch.

Gary touched. He thought he had beaten Anthony and Pieter, who were on either side of him, but wasn’t sure. He had no idea how those farther from him (lanes 1,2,6,7,8) had fared. His burden was suddenly lifted. He removed his cap and goggles and stared at the scoreboard like the rest of us. He looked for the number beside his name and saw a 1. He raised his hand in elation, awe, relief. He saw Pieter smiling and Anthony ecstatic, and reevaluated the scoreboard. There was a second number 1. He assumed Pieter had tied him, and they hugged. Then Anthony leaned over, fervently joyous. Gary looked up again and realized that it was Anthony who had tied him, and Pieter had the bronze. He embraced Anthony, as happy to tie his friend for the gold as to win it outright.

Gary emerged from the pool to a standing ovation. Most Australians were now aware that the guitar quote had been taken out of context. He ambled toward the stands, waving to the crowd. Elizabeth leaned over the rail with a big kiss. Gary then jumped up into the seats to embrace his ecstatic family, and Anne. I scrambled down the aisles to reach the Halls, but the multinational multitudes, milling about, pressed against me and slowed me down. By the time I reached the first row, the Halls were gone.

I sat for a while in the empty first row, staring at the abandoned and becalmed Olympic pool. Gary’s focused resilience as he successfully contended with water and life was more comprehensible to me now. It was sheer force of will that compelled him to succeed; he had determined that he simply could not lose.

Type 1 diabetes is an incessant, demanding illness. Its treatment is highlighted by a scourge of needles, a morass of measurements, and binding nutritional necessities. In 1999, Dr. James Shapiro and his colleagues at the University of Alberta, in Edmonton, Canada, transplanted freshly harvested beta islet cells from newly deceased human beings into eight Type 1 patients. He initially reported a 100 percent cure rate, but currently half of the patients are back on insulin injections. In this trial, the beta cells were injected into liver-associated blood vessels, and, flowing free, attached themselves to the vessels’ lining and began to secrete insulin in a timely and homeostatic fashion. The beta cells flourished, behaving as though they were back home in the pancreatic islets, and resurrected each patient’s carbohydrate metabolism. These patients initially felt close to normal again after many years of impediments.

Despite their competence, transplanted islet cells are threatened by the body’s immune system; it comes to recognize them as foreign and destroys them, thereby fabricating the original disease anew. This threat must be countered by immune-system suppression with toxic drugs. And herein lies the reason that islet cell transplantation remains in the trial stage. Muzzling the immune system with drugs is fraught with serious complications—increased risk of life-threatening infection, kidney disease, memory loss, and malignancies.

Although James Shapiro and his colleagues have proved that implanted beta cells can successfully self-regulate in the recipient, much remains to be done to effect a permanent cure. The production of beta cells must be vastly increased so that they are readily available in large numbers, and the manner of their generation must be simplified. Perhaps the beta cells can huddle within creatively constructed capsules, disguised to prevent immune-system recognition. Thus far, it has been difficult to baffle the immune system once it has turned on specific cell populations within its own bodily mix. Until we find successful encapsulation strategies or selective triggers that might inhibit the immune system, the creation of less-toxic suppression drugs seems essential.

Despite these limitations, we’re seeing the blossoming of a new era of islet-cell transplantation that can be likened to the expansion of liver transplantation in the 1980s. Amid the groundswell of enthusiasm initiated by James Shapiro’s successes, more researchers are working on this problem than ever before, trying to improve on the Edmonton experiments.

Planning a return to the Olympics in 2004, Gary continues to practice 50-meter sprints and long, slow laps sans flip turns. As he does so, semi-submerged and solitary, bolstered by the whirl of churning water, he often reflects on diabetic children. As a diabetes activist, he spends much of his out-of-water time trying to inspire and educate them, showing them all that can be done despite the absence of functional beta-islet cells. He fervently hopes that transplant advances—he stays abreast of diabetes research—will soon allow Type 1 kids to envision the inner surfaces of their liver-vessel walls implanted with beta-cell beachheads from which to win their sweet war.

Spencer Nadler is a surgical pathologist and the author of The Language of Cells: A Doctor and His Patients.

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