Traveling with Sugar. Amy Moran-Thomas
The problem is ugly at any point along its unsavory continuum: At one pole, there is the real danger that images of violence can be viewed and taken up in ways that verge on gratuitous spectacle or even repellent intrigue. Yet at the other end of the spectrum sits an equally chilling truth that gruesome things are already happening to some people, and many in broader publics would rather look away than face their part in the larger systems that depend on unequally patterned injuries—silence that often fosters complicity with even sharper injustices ahead.
All of us holding cameras were dealing with these dilemmas: What kinds of images were usefully sobering, which gratuitously sad? Who gets protected from the grisly side of diabetes? How do we represent this latest chapter in a familiar story of racialized bodies hurt by sugar—when we live in a global economy so deeply shaped by this legacy that even pictures of its echoes could become capital? Yet there was no denying a severe and growing problem that people were working hard to more accurately make public. How to convey that erased reality without dehumanizing anyone in the process of trying to make it visible?
Some patients began to display their injuries for cameras to try making the issue more legible—as you’ll hear later, one dialysis advocate even began improvising “press releases” each time another part of his body was about to be amputated, calling up the major media outlets in Belize and asking people to make and reckon with images. As Laurence Ralph reflects elsewhere about “living through injury,” sometimes “it becomes politically strategic to inhabit the role of a ‘defective body’ in order to make claims about a violent society.” When individuals exhibit and even publicize their injuries to call attention to the broader social injustices shaping them, this can become part of a strategy that Ralph calls “what wounds enable.”6
Belize Diabetes Association groups were facing related questions with immediate stakes: photos of imperiled feet help them to disrupt ideas of diabetes as a boring disease and thus to gather support for material care. For many members, this was not an abstract or theoretical debate about reproducing ideas of suffering. It surfaced instead as a dilemma that was unfolding in real time—as in the first week of 2018, when the Belize Diabetes Association Belmopan branch posted an arrangement of the new year’s photos on their Facebook page.
The image was carefully composed to both shock and counter-anchor in dignity. It was prefaced by the pointed note “Permission granted by clients to share” and the hashtags #SaveAFoot #SaveALife, with pictures of four feet in limbo with mottled and missing toes, stitched to a larger photo of a T-shirt that said:
BEHIND EVERY PERSON WITH
DIABETES
THERE IS AN EVEN
STRONGER
FAMILY WHO STANDS BY THEM
SUPPORTS THEM AND
LOVES THEM
WITH ALL THEIR
HEART
“It seems as if the exotic things get the attention. . . . Having five people with Zika brings the media. It’s very sexy, it’s exotic, it’s front-page news. People getting their limbs cut off, not really exciting,” Dr. W reflected later on diabetes and the difficulties he’s had for decades trying to bring public attention to it. In his words:
I think the problem is that in this world of sound bites, diabetes is not that impressive or sexy. But the damage it does is absolutely horrific. . . . diabetes is expanding and growing at an alarming rate. It’s chewing up your GDP. It’s smothering countries. It’s something that’s really killing how your health system will work in every way.
I think the problem is that it’s not studied. People don’t really know how many amputations are going on. First, there is an occult number: a number not well known. Number two, the long-term effects of it are not well studied in this population. Number three, the transgenerational issues that go along with that. The fear, the worry, the anxiety, the denial. . . . No one is measuring that. It’s just like, yeah, diabetes. It’s in this area.
A report from Belize’s only prosthetic leg clinic noted that of the six amputations attributed to animal bites the previous year, only three had been snake bites. “The other three were attributed to rat bites becoming infected in diabetic patients. Bites from rats speak to the need for improved standards of living.”7 The report added: “Most diabetics from [our] Belize clinic ambulated in flip flops, sandals or ill fitting footwear due to poverty. In addition, they reported having their blood sugar tested once every three months! This very likely contributed to their becoming amputees in the first place.”8
In the U.S. context, for which better data exists, about 80 percent of the country’s total amputations are due to diabetes. But even the broadest literature review on diabetic amputation numbers I could locate did not contain data from a single low- or middle-income country. Despite this limited geography, even narrow studies suggest jarring numbers: About a third of people with diabetes experience an ulcer, and more than 50 percent of diabetic foot ulcers become infected.9 A third of people who seek clinical care for ischemic diabetic ulcers (the most common type) will die before their injuries ever heal.10 Diabetic foot ulcers “have morbidity and mortality rates equivalent to aggressive forms of cancer.”11 After having diabetes-related amputations, over 70 percent of patients die within five years—a death rate second only to lung cancer.12 Following a major diabetic amputation, 50 percent of people will have another limb amputated within two years.13 Despite these troubling fragments of statistics, though, there remains a dearth of global funding for diabetic foot care, due largely to lack of evidence documenting that there is a global issue.
“Internationally, accurate numbers of limb amputations performed are very difficult to estimate as there is no recognized database or organization collecting this information,”14 one journal article about this global data gap recently summarized. The article also noted a brute-force fact that bears repeating: “Amputation of a limb is one of the most severe pains in the human experience.”
Tellingly, some of the best statistics about the global severity of diabetic injuries have been collected by accident. Diabetic amputations have often turned out to be the number one cause of limb loss captured by databases meant to gather information about landmine blasts and other war-related injuries, as reported in studies with titles like “Diabetes or War?”15 Researching the “yawning gap” between the need for diabetic foot care and sparse funding to support it, David Armstrong and colleagues recap: “There is a lack of federally and not for profit–funded research directed toward diabetic foot ulcers. This funding gap is disproportionately large in comparison with the public health impact of this sequela.” The authors call this discrepancy “a clear and present medical and fiscal calamity. We must mind this gap as a locomotive of lower-extremity complications is approaching.”16
The odd turn of phrase that ends their article underlines a strange fact: if the injuries and amputations that their team analyzed had been caused by actual locomotive trains, they would be robustly included in the global statistics that guide health policy funding. The World Health Organization’s recent Global Burden of Disease report, for example, was designed especially to attend to the daily difficulties of living with chronic injuries. Its scale of “disability weights” emphasized the painful toll of amputations on daily life.
But the twenty-six possible causes of amputations and related injuries that the 2017 study painstakingly charted did not include diabetes. It did estimate global amputation burdens, though, for six kinds of traffic accidents (motor vehicle; motorcycle; cyclist; pedestrian; mass transportation, including bus and train; and other road incidents), as well as for venomous and nonvenomous animal bites, domestic violence, gunshot injuries, self-harm, war, and torture.17 This led the report’s authors to conclude that global injuries are declining and the world today is becoming a safer place. I wonder for how many countries in the world, besides Belize, that summation sounds plainly inaccurate.
The last time I visited Belize, I went to see a few friends one weekend and found that three of them had lost a leg since my last visit. The repetition