Traveling with Sugar. Amy Moran-Thomas
instance, some global health programs piloted ways to attach medicines to cases of Coca-Cola in order for treatments to hitch a ride to rural regions beyond health systems’ reach. But in the case of diabetes, this delivery proposal would be an unsettling image. Which is more disturbing: the idea of insulin and metformin pills traveling to remote areas they could not otherwise reach attached to cases of soda, or the present reality of the Coca-Cola arriving alone?
Every local diet that has been dismantled by industrial diets is unique—meaning that any guidelines about eating require local texture in order to be meaningful for people. One morning, I joined a group in Dangriga that gathered to share cooking ideas to modify Belizean and Garifuna dishes for those with diabetes. Inspired by Garifuna cooking projects like Isha Gutierrez-Sumner’s Weiga (Let’s Eat!)84 and Belizean restaurants like Nutrilicious Corner,85 some suggested that events around healthy eating with diabetes might get people talking.
It would be good, they said, to have a locally relevant alternative to the foreign pamphlets that gave the false impression that all diabetes-healthy foods were “white people food.” Grace was there, mostly just listening. Recipe ideas that the group offered included blended greens with milk and nutmeg; boiled raisins with okra, bukut, and vanilla; oven-roasted carrots; beet salad with slivered watermelon; club soda with a squeeze of papaya; soursap leaf and orange leaf tea; and fish dipped in seawater (instead of table salt) for cooking, the way past generations did. Others had questions about local and ground foods, which of course came with no labels. Was toasted cassava safe for people with diabetes? They wondered if local labs could be equipped to investigate the nutritional content of certain dishes or to monitor their fish and water to guard against toxic chemicals.
I initially thought it would be fairly easy to apply for a grant to support the kind of local foods project they suggested. But it turns out that the U.S. National Institute of Health explicitly declines to fund research that generates locally relevant dietary and care translations; they reason that such outcomes would not be globally “generalizable.” If only approaches imagined as “generalizable” receive policy funding, then most well-resourced interventions end up framing what is inside individuals as the problem to target, rather than putting resources toward remediating harms of people’s lived environments.86
When I bumped into Grace later in line as she waited to see Dr. W, it seemed that her foot spoke not only of gaps in the surveillance around injuries due to diabetes, but of displaced watchfulness throughout larger global systems of food and medicine. Her injury seemed to evince the culmination of decades or centuries of policy and legal regulations that contributed to chemicalized water, air, and sustenance; and skewed food options, linked to unjust agricultural systems and long legacies of land dispossessions. Viewed in this way, every amputation is preceded by “a thousand tiny cuts,” as Michael Montoya wrote of diabetes.87 In fact, each end-of-the-line injury like Grace’s (as well as its erasure in much global accounting) could be read as what Marcel Mauss called a “total social fact”—at once economic, political, legal, ecological, institutional, biological, alimental, spiritual, and familial.88 A total social fact demands a total social response. Yet at present, only 2 percent of global health funding is spent on all chronic diseases combined.89
Some months after we last saw each other, I heard the heavy news that Grace had chosen to die with all of her limbs attached. After careful meditation, she made the choice to refuse the amputation of a gangrenous leg. “More people are doing that now,” Norma said when she told me. Looking for a picture of Grace to send to her family, I found only a terrible archive of her feet. My mind kept returning to Dr. W’s words from that day, when he wished out loud that there could be some way to get her to a hyperbaric chamber.
THREE ATMOSPHERES
At some point I started to think of decompression chambers as almost mythical places. Originally developed in the late 1800s in England for recreational and military scuba diving, hyperbaric chambers became widely used in hospitals for chronic wounds in general (and diabetic ulcers in particular) in Europe and North America throughout the 1960s and 1970s.90 Their physics is akin to going deep underwater: the pressure inside hyperbaric chambers is measured on the machines’ gauges in ATAs, Atmospheres Absolute of pressure. At sea level, you are at 1 ATA, experiencing one atmosphere of pressure. Inside of a hyperbaric chamber, each additional atmosphere corresponds to the pressure of being underneath an extra thirty-three feet of seawater.
This pressure helps to saturate blood plasma with healing oxygen. (Plasma is the hay-colored fluid in which the more familiar components of blood, such as platelets and red and white blood cells, travel through the body, helping vascular tissues heal.)91 Even the most stubborn diabetic wounds might have a chance with this boost of intensive oxygen under pressure.
Bodies that stop healing are hard to imagine. Even a minor cut or scrape can’t form a scab or shrink a little each day. A tiny abrasion might look like it had just happened for months, even years. Almost like the injury is frozen while time goes on around it, except that it can still become infected. Preventing infection is work that starts anew each day. But even very old diabetic wounds can often start to heal again if given a few sessions in a hyperbaric chamber. Some studies have even suggested that oxygen therapy is helpful not only for wounds, but actually for preventing the onset of diabetes in the first place.92
These devices activate the body’s healing capacities through the saturation of oxygen-rich air, either directly inside the chamber or through a mask. Originally honed for safety by British naval experiments on herds of goats, today U.S. hyperbaric chambers are marketed even for pets, such as “equine athletes and pleasure horses.”93 At some centers, special breathing masks can accommodate the snouts of certain animal species. Humans, meanwhile, can wear a range of different models: some masks look like the clear bubble helmets intended for astronauts, while other images remind me more of scuba gear or nebulizer masks. Multi-person hyperbaric chambers can be sizeable, like a clinical waiting room with round submarine windows; others resemble an appliance like a huge microwave, with seating for five or more. Some report that the pressure inside feels very slight or even imperceptible but makes your ears pop, like descent in an airplane.
Researching the varieties of these decompression machines, I suddenly realized with some shock that there actually had been hyperbaric chambers in Belize all along. A chamber has been available for decades in a network sustained by Ambergris diving shops, in case any scuba divers experience the bends or other pressure-related sicknesses. As an additional safety measure, a second hyperbaric machine was also added to serve diving tourists on the island.
It turns out that the phenomenon of diabetic limb injuries across the Caribbean coincides with a geography particularly well equipped with hyperbaric chambers: Barbados, Belize, Cuba, Dominica, the Dominican Republic, Dutch Antilles, Jamaica, Martinique, Mexico’s Cancun, Puerto Rico, Saba, Saint Lucia, and Trinidad and Tobago (among others), according to what I could find on websites like Caribbean Adventures and Dive Vacations. Most were located in places citizens would not think to turn to for diabetes care, such as marine parks, fisheries, nearby scuba shops, and inside army bases.94 I watched a video of one, then asked Dr. W if he had time for a call, to make sure I wasn’t misunderstanding.
“Are these the same machines that can prevent diabetic amputations?” I asked him.
The short version of his answer was “Pretty much . . . but it’s really complicated.”
The long answer would be something anthropologists might call a “socio-technical problem,” since it’s hard to separate technological limits from the way human societies position and use their devices.
In the United States, health insurance often covers hyperbaric treatment for diabetes ulcers, billing approximately $350 per dive as long as the specialist is accredited by the Undersea Medicine and Hyperbaric Society. But in parts of the world labeled as lower income, insurance reimbursement apparatuses are more complicated and oxygen more expensive per tank. And diabetic sugar’s wounds, unlike diver’s bends, are almost never a one-time fix. Additionally, most scuba divers with decompression sickness quickly recover. But the most serious diabetic ulcers might require session after session of dialing the