The standard legal definition of trauma is “a wound or a condition of the body caused by external force, including injuries inflicted by bullets, explosives, sharp instruments, blunt objects or other physical blows, chemicals, electricity, climatic conditions, infectious diseases, radiation, and bacteria, but excluding stress and strain.”20 Limbs injured or lost to sugar are thus not considered traumatic because they take shape slowly. When it comes to these non-traumatic diabetes wounds, in hospitals around the world, tough choices get made at the time of amputation. For instance, surgical teams must decide whether to use limited supplies of anesthesia to render a patient unconscious or to only numb them at the waist. In the conscious version you are awake and listening to everything. Bone has to be screwed to the table before they saw it. One woman in Dangriga told me she prayed so hard and felt her family’s love so palpably that when the drill started up she felt the grace take over completely, and her ears filled with a loud ringing so beautiful that it became the only noise in the room.
“There are so many miracles,” she told me. “Thank God.”
DISPLACED SURVEILLANCE
Long after she officially retired, Nurse Norma kept going to the hospital to help provide diabetes foot care. She also made certain home visits, even though she no longer got paid for the work. She heard that specialized diabetes foot training will be coming soon and said she will start to relax her watch if she gets an apprentice. In a district where so many were losing limbs, how else could the only person certified in foot care training truly retire?
Humans alive today, in general—and nonwhite people, in particular21—are subject to constant surveillance. Algorithmic tracking and facial recognition tools are on the rise, alongside what Alondra Nelson calls “data spillover,” cases when even materials like saliva submitted for ancestry testing or photos shared on social media can be harvested as data by interested parties ranging from pharmaceutical and life insurance companies to law enforcement databases.22 We have never had more information collected about us by companies and states. This made it feel even stranger to come across the rare case where members of the concerned population actually expressly wanted institutional “surveillance” collected about key data—only to find that this data remained elusive.
“A lack of surveillance in Central America has stalled the development of amputation prevention services,”23 one prosthetics maker in Belize noted. Here’s the catch: it takes numbers to redirect global policy money, but it takes global policy money to assemble the numbers.
Belize has made more headway around these uncomfortable numbers than most Central American and Caribbean countries. A very small study incorporating data from Karl Heusner Memorial Hospital (Belize’s only tertiary care hospital) was written up and published by concerned physician Uldine Wright, who recently returned to Belize from medical training in Cuba. She recounted a tally showing that among patients who came to the Belize City public hospital to treat a diabetic ulcer (often caused by an ingrown toenail or similar tiny wound), 89 percent of patients received an amputation.24 Some 29 percent lost their leg below the knee, and 24 percent lost the limb above the knee. I heard informally that medical interns do many of these cuts. Eighteen percent of amputations were trans-metatarsal (toes or fingers with a piece of the foot or hand), while 18 percent lost only digits (mostly toes). Twelve percent of patients healed with debriding, and 0 percent healed with conservative treatment.25 The second hospital that Wright also studied showed a less pronounced but still alarming figure: 24 percent of patients who arrived for diabetic ulcer care received amputations.
Even a tiny snapshot like this begins to suggest some sense of how normalized injuries impact care across the board—physicians upset with patients for not coming in earlier; patients terrified to seek care when they know the significant probability of returning with an amputation. There were tensions about which cuts were possibly avoidable or totally necessary, everyone struggling to bear their piece of the intensity.
From what I could observe, the caregivers most routinely dealing head-on with diabetic injuries were mostly Black and Indigenous women. They made up the majority of the community health workers and nursing and medical attendants with whom I spoke. Their expertise was formidable, but their labor offered little way out of the intense sensorium in which rural health workers practiced their craft. It took time to learn unwritten care strategies, a Garifuna rural health worker named June explained to me as she recounted the story of the first time she had cared for a diabetic foot: “I just told the patient, I’ll be right back!” The older Garifuna nurse with whom June was apprenticing later praised how artfully she had concealed the pause when she went outside and vomited.
“If the patient sees that you are scared, they will be scared too.” Nurses taught each other techniques to steel oneself to unwrap a diabetic foot, since “you never know what is going to be under there”: for example, to be ready for larvae so that anything else is good news; or how to take the cap off the bleach bottle before you open anything else, and then just focus on the bleach smell. June described learning to swallow her dread while calming patients’ reactions if they looked down at their foot by telling them stories about similar diabetic limbs that ended in some form of recovery. She said this was not the work she imagined. “Laugh, don’t cry,” she added.
I once fell into conversation with a team of care workers in Belize wearing matching bright green “EYES ON DIABETES” T-shirts. The printed design on their backs featured watchfully gazing eyes. I found myself thinking about how the assumed optics of functioning health surveillance had been displaced. In the gaps of accurate foot care epidemiology being conducted by global institutions, it seemed to me, not only were care workers “improvising medicine” to blunt the impact of diabetic injuries, with care practices full of the ad hoc force that Julie Livingston memorably describes around another chronic condition.26 Members of these makeshift networks were additionally improvising select forms of surveillance, akin to the multiplied perspectives that some have called “para-sighted” optics—teaching each other new ways to see, keeping their own counts of emerging patterns, watching out for each other.27
People I met improvised daily surveillance of their own bodies: obsessively checking their skin for scrapes or soft spots, enlisting others to help check the bottoms of their feet, praying to spirits for help monitoring. At one meeting I attended in the municipal building of Dangriga, the crowd of mostly women sitting in blue theater seats taught each other strategies for making a physician see their feet. “Untie your shoes ahead of time, while you’re waiting. Then stick it right on their desk. Just tell them, ‘Well Doc, I am about to put my foot right up on your desk!’” Everyone laughed, nodding. It was a good joke to remember: make the busy Cuban doctor laugh, buy an extra minute of their overstretched attention.
Nurse Norma and the Belize Diabetes Association on watch.
The Diabetic Foot Center Group that Dr. W founded and heads recently launched a new program in their travels across the Caribbean: visiting the proprietors of nail salons to teach them signs of diabetes ulcers. This network of beauty shop technicians is now helping to refer clients to hospital care when their hands or feet are in danger.
As Dr. W described initiatives like this, his words kept returning to two observations that are hard to square with each other: on one hand, the public has no idea what is happening; and yet, this is very well known by those who know it. What was happening in the space between these two truths? After