In some opaque way, the “ordinary” sclerotic surgeries in a Dutch hospital have a historical relationship to the absence of those restorative technologies in most of the Caribbean. They are obliquely connected by colonial histories of plundered bodies and lands that still today shape institutional resource flows—systems impacting how different forms of medical expertise and technologies developed. To extend Mol’s logic to Belize, these “versions are both different and interdependent: multiple.”63 “The capital amassed in the eighteenth and nineteenth centuries through various forms of slavery economy is still in circulation,” W. G. Sebald wrote, reflecting on what he called the “money laundering” of Dutch art funded by Caribbean sugar, “still bearing interest, increasing many times over and continually burgeoning anew.”64
There is also another aspect of “diabetes multiple” that is not easy to trace with hospital observations about disciplinary differences alone. Technologies do not get used equally, even in affluent hospitals, for reasons that occur without the intent or knowledge of anyone involved. In textbooks about sclerotic arteries, for example, the choice of which procedure gets used should not relate unjustly to an individual patient’s skin color. But looking at U.S. population data, it becomes clear that racial assumptions have been systematically enacted on patients’ bodies.
Drawing from ten years of New York hospital data, one study analyzed 215,000 cases of people with diabetes arriving at the hospital with symptoms of peripheral artery disease.65 It found that Black patients were 46 percent more likely than other patients to have received an amputation instead of a “salvage” procedure to restore blood flow to their legs. Black patients and women were also more likely to be amputated above the knee rather than at the shin. Above-the-knee amputations notoriously make recovery much more difficult.66
Perhaps most disconcertingly, these disparities were actually highest in the hospital units with mostly white patients, so they cannot be easily attributed to preexisting resource or equipment inequalities of segregated cities. Another study mapped the geography of diabetes-related lower limb amputations in Los Angeles, which is actually the largest Belizean city in the world by population. This mapping revealed that people were ten times more likely to experience diabetic amputations in the poorest areas of the city, which were also the most segregated. It shows a disturbingly patterned geography of “diabetes multiple”—inequalities that can make diabetes a physically different condition for people of color and for patients with fewer resources, those more likely to have limbs removed even when experiencing identical symptoms.
Certain scientists still argue that diabetes risk is “inherent” in the DNA of nonwhite people. This text instead follows Anthony Ryan Hatch’s illuminating work in Blood Sugar—including his observation that “race is not biological, but racism has biological effects.”67
In hospital labels, the technical name for diabetes is diabetes mellitus. It derives from the Latin word mel for honey, a reference to an old European medical trick of tasting a patient’s urine for honey-like sweetness as part of the diagnosis. Physicians today commonly shorten diabetes mellitus to “DM.” In contrast, the word sugar was adopted into Latin from the Arabic word sukkar around the time sugarcane was adopted into imperial Rome from its plundered colonies. And in the clinics and homes of Belize, people were constantly reworking this label of “honey diabetes.” No, many insisted: they had sugar diabetes.
Not everyone I spoke with in Belize described their condition as “sugar.” Relatively well-heeled patients, more able to manage, were more likely to say they had “diabetes.” The terms slipped into each other constantly. But I noticed some patterns.
For many with diabetes, an event like dying young or losing a limb would register as a surprise, even an outrage—either would be shocking, for instance (by way of contrast) among those with diabetes in my white, middle-class extended family in the United States.
Sugar, on the other hand, I often heard in relation to societally normalized injuries and untimely deaths. Living in foretold death and injury meant that something terrible not happening was also newsworthy. Sometimes I found those comments more haunting than the bad stories. One man told me of his mother, “She died with all her arms and legs on.”
The long fights to which a foot is lost to diabetes often remain illegible as “battle scars,” Kiese Laymon writes in Heavy—and “unacknowledged scars accumulated in battles won often hurt more than battles lost.”68 Unacknowledged scars of sugar could be read as one of many distillations in the “climate that produces premature Black death as normative,” in the words of Christina Sharpe69—or for others, as part of “the labor of living in the face of an expectant and a foretold cultural and political death,” as described by Audra Simpson. “With settler colonialism came . . . a radical shift in Indigenous diets and their bodies. As a result their blood is excessively ‘sweet’ and has a high prevalence of diabetes—a bodily indicator of these spatial and dietary transitions.”70 Seeing disembodiments happen to others only deepens existing traumas, as Mojave poet Natalie Diaz captures of diabetes and surviving such losses: “Asks me to rub her legs which aren’t there so I pretend by pressing my hands into the empty sheets/ Feels she’s lost part of her memory the part the legs knew best like earth/ Her missing knees are bright bones caught in my throat.”71
The racial logics of normalized injuries and death that distinctly characterize both settler colonialism and white supremacy72 came together in sugar for some like my friend C, who was proudly Garifuna—both Black and Indigenous. She was among those who told stories of her doctor’s shock when she returned to the hospital for a long-held appointment after the diabetic crisis he had assumed would cause her death at age thirty-four.
“He said, ‘How are you still alive?’” she really laughed, mimicking his wide-eyed incredulity. It was the hardest that I ever saw her laugh, so I laughed too, but looking back on it I only saw a surface fraction of the joke back then. I appreciated her comic critique of biomedical limits. But I missed the eerier echo of implicit memory: her ancestors had been facing expert iterations of that very same question—How are you still alive?—ever since the first European surgeons arrived on the warships sent to eliminate them from Saint Vincent.
Normalized death, extraordinary survival, transformations that became necessary to live on—whatever expectations sugar indexed, this was the closest thing to a refrain that I encountered across individuals’ stories. People regularly showed up in clinics with blood sugar levels that textbooks said would be fatal. Doctors, caring, confused, faced with sugar escaping the biomedical rubrics of diabetes mellitus, would ask: “How are you still alive?”
STILL. THERE
When I loaded the microfiche about Confederate plantations built in Stann Creek, the first slide said in huge letters: “END.” The reel must have been spooled backward on its last rewind, but it felt fitting—the traces of sugar that it held were the opening frames for the afterlives I was trying to learn about. My vision blurred while scrolling through Samuel McCutchon’s papers: letters, maps, almanacs, sketches, clippings of machines he hoped to buy. His favorite was called “The Concretor,” a device that turned sugarcane simultaneously into molasses and its byproducts into concrete building blocks.73
It was strange to see McCutchon’s bookkeeping straddle countries and decades. In pre-emancipation United States, the enslaved people he legally owned were listed by name alongside his estimation of their dollar value. In southern Belize, he used the same notebook brands and page formats, but this time the price column marked a minuscule hourly wage. The lists contained many last names of Kriol and Garifuna families