You can see them by the side of the road. Lonely little signs, emblazoned with phrases like: “Ca$h 4 Diabetic Test Strips,” or “Test Strips 4 Ca$h,” with a phone number underneath. The signs look fairly non-descript, like innocent, forgettable scams. But at the root of it all is the diabetes black market, and a narrative that has everything: big money, big corporations, and sinister dealings conducted in car parks.

Let’s face it: the everyday of diabetes management is pretty dull. Test; inject; repeat. It’s kind of nice to know there’s a seedy underbelly to the whole thing.

The seedy underbelly of blood glucose testing

Person A is just a middleman. None of it was his idea. He just goes from place to place, picking up unopened boxes of test strips. The real work, the thinking, is done by someone else. It’s their system.

It’s a very clever system. Person B has health insurance, so they get some cheap(er) boxes of test strips, more than they actually need. In some cases the test strips will be free, and in other cases they will cost, say, $10. Person B sells on the excess to Person C, netting around $20 in the process. Person D doesn’t have health insurance, so a box of test strips can cost more than $50. Instead, they buy their test strips from Person C, for maybe $40. Everyone’s a winner.

None of this is illegal, so long as the suppliers (Person C) register with the Food and Drug Administration. Most don’t, but the government’s too busy cracking down on prescription fraud to worry too much about them most of the time: “I wouldn’t say it’s under the radar,” says Wanda Fischer, a spokeswoman for the New York State Office of the Medicaid Inspector General, “but we have a lot of other issues that we’re dealing with.”

The cost of test strips

None of it would be necessary if test strips weren’t so expensive – in some cases, more than a dollar per strip. Without insurance, it’s a wonder how anyone can afford to test as much as they should. “I’m not surprised there’s a black market,” says Dr. Matthew Leinung, an Albany endocrinologist. “Everyone’s making money on the strips because people have diabetes their entire lives and they need a never-ending supply.” The black market provides an alternative, a way for people without insurance to take care of themselves without spending every cent they have.

But if it sounds like a progressive future in which money is taken from the rich and given to the poor, the system is not without its problems. For one thing, you can’t be sure the test strips have been kept in the right condition – they have to be kept at room temperature – or that they haven’t been ruined in transition. “Patients need to question the integrity of the products they are buying online,” says David Winmill, a nurse practitioner and Certified Diabetes Educator who practices in Ogden, Utah. “It’s impossible to guarantee that the strips purchased from a third-party were maintained in a certain environment.”

Others consider it irresponsible. It drives up the price of insurance for everyone else, they argue, because medical costs go up and up. It’s not the people who buy second-hand test strips that feel the effects; it’s people who play by the rules. But if there were alternatives, if test strips were made more affordable, nobody would do things this way. Who actually wants to stand in a freezing car park waiting to be supplied with test strips that aren’t completely reliable anyway?

Help is available

According to Winmill, legitimate help is out there. People who are struggling should look to other, less shady options, he insists: “There are many resources that we have access to that can help patients receive the equipment and supplies they need from reliable sources.”

Lilly Cares, for example, provide discounts on Humalog insulin; Novo Nordisk’s Cornerstones4care program makes Levemir and Novolog insulin cheaper; and Sanofi offers Patient Connection, which provides the same service for Lantus and Apidra insulin.

The black market will march on, with its victims and its victors, until something gives, until the difficulties experienced by millions of people with diabetes is addressed. It’s strange to think that people will go so far for a humble test strip. And even stranger to think that they have to.