This article discusses the evolution of therapy for type I diabetes and considers how physicians should be thinking about the disease in the late 1990s. The biases herein are that management strategy has evolved such that contemporary practice should routinely entail a system of “flexible intensive therapy” directed at meticulous glycemic control; that to accomplish this requires a skilled management team including an educated motivated patient and family working in a negotiated therapeutic alliance; and that a further goal should be the development of effective approaches to interdict the pathogenetic process such that disease prevention is possible.