Many of the “fixes” addressed to normalize sugar seemed not only to fail to contain its loose forms but also to generate additional harms: from pesticides that poison bodies even as they protect crops, to foreseeably insufficient and unevenly accessible care technologies, to the excesses of violence and insecurity that trail long histories of lost lands, foods, and families. With these legacies unleashing material forces, diabetic sugar’s normalized losses emerge from a machine five centuries in the making—overgrown and breaking down yet proliferating and exceeding many remedies meant to triumph over it.
A Confederate sugar machine at Indian Church, Belize.
Over time, I observed experts try to put sugar in many different enclosures. In one archive, I saw pressed sugarcane plants get filed in niches labeled as “pigeonholes,” each numbered. The Kew collection in London included many indigenous plants and vegetables from Central and South America and the Caribbean that are now extinct in the wild, making me realize I did not know of any extinct species of sugar. “Unfortunately, our sugar collection is mostly just tassels,” one caring botanist told me regretfully as she handed me folders of wheat-colored bristles from the Americas, mostly from Mintz-era Puerto Rico. The botanist kindly added that she wished they had more cane stalks on file so that she could show me sugar’s unusual joints. “Try to think of them like knees,” she said. Much later, driving past a patch of cane sprouting along the road in Belize after a day spent talking about lost limbs, I thought of the London analogy’s misfit; only sugar keeps growing back.89
Yet if sugar was still there, so was Sarah’s family. And given the heaviness of history that preceded our encounters, I felt surprised by Sarah’s generous parting words in 2010: “It’s a great time to be together. You know, love one another, talk with one another. Feel happy to know that you know someone strange. Make the best of it, love.”
What Is Communicable?
Caregivers in an Illegible Epidemic
The body isn’t wrong, isn’t “disabled.”
The environment itself—gravity, air, solidity or the lack of it, etc—is what is somehow wrong: ill-matched to the body’s abilities . . . verticality, stability, or mobility.
She . . . whose limbs struggle to accomplish their given tasks on earth is, in this sense, like an astronaut: far away from home, coping.
—Teju Cole, Blind Spot
By the time we met in southern Belize, Dr. W had already named it in his mind: the “Caribbean diabetic limb crisis.” He said he hoped someone does a study about the trauma caused by diabetes amputations, and not just for patients. He said someone should also do a study about trauma for surgeons who are being put in the position of repeatedly removing pieces of their patients.
It took me a moment to put together the fact that Dr. W was one of those surgeons.
“You can’t imagine how much I never want to see another person lose their foot,” Dr. W would tell me later. “But I know that each day I do this, that’s what’s coming.”
Sarah’s younger brother, an animated man named Tobias, was among those I saw greet Dr. W with a warm handshake. He and his wife had traveled to Dangriga just to say hello to him. I began to grasp why, when Tobias recounted an odd story to me: A few years ago, he was walking and a bone fell out of his foot. He barely even felt it glide out from the lesion that a diabetic ulcer had eroded in his tissue. Tobias picked his bone up off the floor—a joint below his toe—and took a picture of it. Then he placed the bone in a clean plastic bag.
Dr. W at work, Dangriga.
Later, Dr. W described the photo and message he had received from Tobias: “He called one day from Belize and said, ‘Hey Doc, this bone fell out of my foot this morning. It didn’t hurt at all.’ And I thought to myself, you know, this really isn’t okay. It’s almost . . . Frankenstein-ish. But it doesn’t raise any real alarm. That tells me a lot about where things are, when people are kind of . . . used to it.”
Archaeologists say the world’s oldest known prosthetic appendages are mostly toes, fashioned nearly three thousand years ago in ancient Egypt out of wood, leather, linen-like plant fibers, and glue.1 By 2010, I never met anyone who bothered for “just a toe.” But if you looked at the sandals of the people gathering in line, you could see that a number were missing toes. Those waiting to see the doctors appeared to be from all walks of life: stylish fashions and threadbare clothing, many formidable in stature but others looking markedly thin, a mix of skeptical-looking teenagers and grandmothers in weathered hats. The arriving members of the Belize Diabetes Association’s New York branch and their colleagues from Dangriga and the Belize Ministry of Health unpacked supplies for the day, arranging stations around an open pavilion. The team’s mood was relaxed and convivial. Only their gear, plastic boxes packed with foot care instruments, hinted at the day’s high stakes.
Dr. W’s team brought a stack of photocopied papers, titled “Limb Salvage Form.” These sheets displayed sketched outlines of feet: a right and left foot shown from both bottom and top view, with circles outlining the twenty-two quarter-sized places on a foot where podiatrists test for sensation to detect any signs of lost feeling. (“Can the patient see the bottom of their feet?” the paper asked, just above a question about the safety of shoes.)
The Belize Diabetes Association collaborates with Dr. W’s Diabetic Foot Care team, which since 2004 has been traveling between their New York City base and a range of Caribbean countries. Their group focuses on foot maintenance checkups, only one station among an array of services being offered around the pavilion. When requested, they provide training to build expertise among local caregivers and the Belize Nursing Council. On occasion, Dr. W also performs follow-up salvage surgeries to restore a diabetic limb that may have already been scheduled for amputation. The medical word salvage has a particular echo in the history of social observers: some early anthropologists imagined forms of “salvage ethnography” to document people and practices they prematurely labeled as dying off.
The team’s practices of salvage here, in contrast, signaled the very opposite of resignation to harm. In medicine, the term salvage means that all possible measures are being taken to ensure an ailing limb stays alive and attached. Limb salvage procedures often include vascular surgery measures to restore blood flow, such as unblocking blood vessels or placing stents. They most broadly demand the careful monitoring of feet to catch tiny wounds before anything reaches a crisis point.
This labor has its own lexicon. I made lists of unfamiliar terms in my notebook.
Claudication comes from the Latin verb to limp, the name for stabbing leg pains caused by restricted blood flow. This is often linked to peripheral artery disease, which most doctors just call PAD. Debriding means removing dead tissue to try to give the living parts around it a chance to grow back. The paperwork’s “Deformities” box holds checklists of things you did not know could go wrong with parts of your feet you did not know existed: Dorsiflexed first ray means that the foot segment containing the first cuneiform and first metatarsal bones rides high; there are two other checkboxes nearby on the page to indicate a concerning equinus (flattening arch) or troubled calcaneus (heel bone). (The feet’s cuneiform bones are wedge-shaped, which is how they ended up with the same name as the ancient Mesopotamian pictographic script once etched on clay tablets with wedge-shaped writing tools.)
Hallux limitus is an arthritic condition of the big toe, with rearfoot and forefoot varus varieties. A bony prominence of the great toe joint causes severe pain and rigidity. There are varieties of toe deformities—hammer toes, claw, and mallet—and three types of corns that classically afflict them. The physicians paid close attention to each detail, trying to tune out the long lines of people waiting around them. Any