And a very serious acronym: LOPS, or loss of protective sensation. Dr. W’s team had set up a station to teach people strategies like using their hands to feel inside their shoes before putting them on, since feet numbed by diabetes can be felled even by tiny injuries. The need for amputation can often be traced back to a sharp pebble in someone’s shoe or a bug bite in the wrong place. One U.S. study about the causes of diabetic limb amputation found at least twenty-three unique causal pathways at play (including 46 percent lost to ischemia, 59 percent to infection, 61 percent to neuropathy, 81 percent to faulty wound healing, 55 percent to gangrene, and 81 percent to initial minor trauma). Those numbers add up to 383 percent instead of 100 percent because most amputations are caused by several mechanisms simultaneously—which is also why remediating any one pathway will not necessarily save a limb. The biggest pattern this study found was that up to 80 percent of amputations were preceded by a “pivotal event,” usually a minor cutaneous injury.2 In Dee’s case, the pivotal event that led to losing her left leg was stepping on a seashell. It was as small as a tooth, just one sharp edge.
It turned out that several of the team’s visiting doctors were originally from other parts of the Caribbean as well—part of a larger Caribbean Diabetes Initiative—and had connected in New York with the Belizean group. People from Dangriga kept telling the team that the letters on their T-shirts, BDANY (Belize Diabetes Association of New York), resembled a Garifuna word meaning “your time”—and, by way of this little joke, let the BDANY members know they were grateful for their time.
“You have salt or sugar?” old friends called out to each other across the pavilion.
(“Both” was the most common answer—diabetes along with hypertension.)
“I never thought you were sweet!”
No matter how many times we heard some version of the joke, everybody laughed.
FOOT SOLDIERS
“She’s one of our best foot soldiers,” Dr. W smiled as he and Nurse Norma hugged hello. Years ago, he had arranged for her to complete diabetes foot care training. It was tough work: of the twenty-five nurses who began the two-part training, Norma was the only one who returned for the second year to complete it. In the months or years between visits from the Belize Diabetes Association’s New York team, Norma stood as the front line of defense for those needing diabetes limb care in town.
Norma’s brother says she has nine lives, like a cat. As a steadfast nurse and head of the local branch of the Belize Diabetes Association, she had managed to maintain herself with type 1 diabetes through many decades and to help keep many others intact. In the southern district of Belize at that time there were no known endocrinologists, podiatrists, or other caregivers who had specialty training in diabetes foot care except for Norma. Her particular expertise included tending to diabetic toenails, a crucial skill: one clip at the wrong angle could lead to a jagged ingrown nail and later necrosis. Toenails also archive: some researchers measure their glycation to detect diabetes and its sequelae of organ damage.3 Trimming required complete attention, at once rough and delicate. Afterward, Norma usually said something deadpan to her patient that I could not follow in Garifuna, and they would both laugh.
The blue plastic tub labeled FOOT CARE quickly piled high with sterile medical wrappers and used gloves. Carefully emptied, it soon filled again. When a tall woman slid off her sandals and revealed four self-bandaged ulcers across both feet, Dr. W stood nearby as a collaborating physician tended to her. I knew the woman, Grace; she was part of a group that had showed up previously when I advertised on local TV and radio an upcoming presentation sharing early findings of this project on diabetes in Dangriga. I watched as the visiting doctor brushed sand off Grace’s toes, then used a Duplex Doppler device to listen to Grace’s feet for calcium blocks or other subtle acoustic clues, pressing with a wand that amplified the sound of blood flowing through the arteries.
Grace was already missing one of her big toes. Crumbled scar tissue and a protruding bone suggested that the digit had broken off with dry gangrene rather than a surgical cut. Making jokes about pedicures, the doctor took the foot firmly in hand and asked Grace to close her eyes. The physician used an array of soft-point brushes and metal hammers to detect where and how Grace’s nerves had numbed or deadened. Then she rubbed Grace’s feet vigorously with soap until enough dead skin sloughed away that the ulcers began to bleed at the edges, which might make regeneration possible. The newest ulcers were perfectly round circles, bright raw pink and eerily symmetrical. But the doctors were more concerned about how her feet sounded: they could barely hear a pulse near her missing toe, signaling diminished blood flow in the tissue that would make it much harder to heal.
Dr. W wished aloud to the team that there was some way they could give Grace two days in their New York hospital’s hyperbaric chamber, the enclosed apparatus that can help otherwise impossible wounds begin to heal. “Is there any way you can get to New York, dear?” His invitation hovered in the air for a moment. But that afternoon, nobody knew a way to access a hyperbaric chamber. After Grace’s remaining nine toes were wrapped in fresh bandages, her flip-flops would not fit over the dressed wounds. The doctors could only laugh in admiration at her raw tenacity when they saw her afterward climbing onto a bicycle. They knew the big toe is particularly crucial for balance, yet Grace moved with steady poise. Someone snapped a photo of her posing with gauze-wrapped feet pressed to the pedals, but their smiles looked privately worried. There was nothing left to do for the moment. We all watched as she rode away.
With an intensely focused look, Norma pulled another hurt foot onto her lap.
NON-TRAUMATIC MEASURES
The surgical unit where so many amputations took place had a sign near the doors reading OPERATING THEATRE. Everyone’s use of “the theater” to refer to surgery rooms gave the events of amputation a surreal quality; I always found this label for medicine or war disquieting, like some script born elsewhere being played out time and again. Surusia, the Garifuna word for any biomedical doctor, comes from an ancient French word for surgeon.4 The term should be a relic from the age of colonial warships when surgeons were literally at the front lines, but it has uncomfortable resonance in the age of epidemic diabetes.
Dr. W worried that even many caregivers do not understand what their patients with diabetes go through in rooms like this, which hold kinds of expertise that nobody wants to hear about: types of gangrene (wet, dry, gaseous), varieties of instruments (pneumatic bone saws, Gigli wires, Zimmer drills). “If you’re not a surgeon, you’ve probably never seen an amputation,” Dr. W noted. He recently jolted one audience of nurses and doctors at a Barbados hospital by starting his lecture with pictures of a procedure.
“And they were horrified. Horrified! Now, of course, they’re medical people, and they’ve seen many things. They’re not squeamish and upset about blood. But when you actually see an amputation, it leaves an impression on you that you will not soon forget. Then I took it from that point and said to them, ‘so every patient who you know is going down this road will have this experience.’”
Dr. W explained that he was working on a new lecture. “During the [U.S.] Civil War, everyone was getting amputations because of major gunshot wounds. That is the only other time I’ve ever seen a picture where you have stacks of legs in a setting. What’s the trauma here? It’s almost like we have a civil war going on in these countries every year, [in that] we have the same number of amputations. In many cases, maybe more amputations. . . . So can you imagine us having civil war trauma, over and over and over again. Unrelenting, unrelenting. Unabashed. Uninterrupted.”
Dr. W’s civil war imagery made me recall how his medical specialty is more formally referred to as limb “reconstruction.” In drawing analogies between diabetic injuries and war photos, Dr. W described a tension that many have grappled with: the twofold problem of looking or not looking at such visceral images, and how to weigh the choice to make them public or not when valences of shame haunt either option. “I could have looked . . . until my lamps went out and I still wouldn’t have accepted the connection between a detached