Dr. W was very hopeful that more portable devices featuring aerosolized oxygen in transportable bags may become accessible for diabetic wound treatment around the world in the near future. He sent me a link of a YouTube video showing the new technology, and we left it at that. From what I could read between the lines of “it’s really complicated,” Dr. W’s decades of work across the Caribbean had taught him that a transportable device his team could carry with them would work well. But it had not proven easy to get citizens access to infrastructures of hyperbaric chambers that exist in their own countries.
For instance, when Sarah’s brother, Tobias, had texted Dr. W that picture of the small bone that fell out of his foot, the only thing Dr. W could think to do was invite him to travel over three thousand miles from Belize to New York City. The treatment for Tobias’s foot lasted over a year. When receiving optimal care in a hospital, diabetic ulcers still have surprisingly long median healing times, between 147 and 237 days.96 In Tobias’s case, treatment with Dr. W and his colleagues included not only dozens of sessions in a hyperbaric chamber but also a wound vacuum-assisted closure, antibiotic beads, and grafts to treat the bone infection. Dr. W helped him find a place to live near the hospital, and his network of colleagues found a way to cover the treatment costs. Tobias’s neighbors and family all chipped in to help with his plane ticket.
Human solidarity is an elusive thing. One of the most famous early social thinkers to theorize it was sociologist Émile Durkheim. It is a lesser-known fact that Durkheim’s influential ideas about social coherence were shaped by his obsession with the era’s new sciences of bacteria behavior.97 He suggested that community and communication shaped each other—since social groups impact how perceptions turn into concepts, “communicable to a plurality of minds.”98 In this view, communicability—the ways that biological conditions are transmitted between bodies—is impacted not only by our communication about them, but also in turn by the communities that take shape (or not) to respond.99
This, too, is integral to what I came to see as the para-communicability of diabetes: not just a different framing for explorations of causality but one that implies a more wide-ranging model of public response; “not to ignore difference, but to create alter-relations with one another,” in the words of Kristen Simmons.100 Hyperbaric availability for scuba divers is precisely designed to offer a safety net so that pleasure seekers can indulge in risk, yet have the option of rescue if they would die without it. This logic of care was not being extended to those dying from diabetic injuries. Between these two scenarios lurk many uneasy questions: What counts as an extraordinary measure, for whom? Whose lives are valued as worth rescuing and at what cost?
When I called the largest hyperbaric clinic in Belize, I learned their machine simulates dives of up to 165 feet. Staffed by a specially trained physician, the chamber is “multi-space,” meaning it can hold more than one person and accommodate others coming or going midsession. When I asked if it could be used to treat diabetic injuries, the curator replied that scuba divers at times receive care for coral-related injuries, and indeed it could also be used on diabetes wounds. It cost three hundred U.S. dollars per session. She added that for patients with U.S. health insurance, the copay went down to one hundred U.S. dollars.
It has become customary to talk about globally unequal infrastructures in the language of “Global North” versus “Global South.” But this geography kept taking on more complicated shapes, when trying to describe either outposts of U.S. insurance–accepting technologies available to those in the know in Belizean dive shops; or the checkered maps of cities like New York and Los Angeles, where diabetic amputation rates increased exponentially in correlation with poverty and segregated spaces.101 These internal inequalities get smoothed over in maps based on countrywide averages. Hyperbaric chambers were another uneasy reminder that even in the same places, we live in segregated atmospheres—racialized climates that pattern out both inside the United States and within most any country, including Belize. And as James Baldwin once wrote of the psychic and bodily effects of racial segregation: “One is always in the position of having to decide between amputation and gangrene.”102
Stock photo of a hyperbaric chamber in a dive center.
My first impulse was to visit one of Belize’s hyperbaric chambers, as if that would somehow resolve the contradiction. I had never been to San Pedro and wondered if Norma might go with me. But when I broached the subject as we chatted on the phone one morning, Norma said she had never heard of that machine and didn’t think one existed in Belize. I looked down at my notes from the dive network’s clinic, unable to put their price list together with the insights from someone who had spent so many years in diabetes wound care—all the patients Norma had worked with over time to pull back from the brink of loss, and all those like Grace she had seen die without hearing of any possible remediation measures that existed.
It didn’t feel right to press harder about the idea of a trip together. But I found enough words to repeat to Norma how it was the kind of machine Dr. W had used to treat Tobias’s foot in New York. The phone line got silent for a minute. We probably each had our own fantasies and doubts about the potentials of such an elusive apparatus. In the moment of quiet, I wondered if Norma was trying to imagine it, too: the pressure, the oxygen, the slow hours of boredom and excitement. The blood starting to move again through skin and tissue that had seemed dead. The feeling when sensation comes back.
I kept remembering how everyone laughed when Grace struck a jokester pose for someone’s camera and then waved without looking back as she rode down a dirt path on her bicycle. There is no consensus about the larger worldwide pattern her trajectory is part of: the World Health Organization attributed 1.5 million deaths to diabetes at last count, but the International Diabetes Federation estimated this number to be 5 million deaths each year.103 Recalling that last glimpse of Grace, in my memory she is riding straight into the place where it has come to seem normal to annually lose track of millions. People moving through these strange infrastructures bring us to another scale where, as Teju Cole writes, “The death toll is always one, plus one, plus one. The death toll is always one.”104
This is it. This is the plague of our lifetimes.
It is by no means simple.
It’s like a long hallway, or a maze.
In Belize, you know the Blue Hole where people deep dive?
When you go into the depths of it, you find that it’s a whole other world.
I see diabetes as being like that.
I think people in the public need to be taken by the hand
If you could convey any of this in writing
Sometimes it reminds me of the Twilight Zone
Welcome to the strange world of diabetes
It is very different than what you have been taught
Come take a look from the inside
It’s not what you think from out there.
—Dr. W, New York City105
PART TWO
Crónicas
Crónica One: Thresholds
Traveling an Altered Landscape with Cresencia
To return once more to diabetes . . . it can strike man or woman, threaten them with coma, often hit them with impotence or sterility, for whom pregnancy, should it occur, is a catastrophe, whose tears—O irony of secretions!—are sweet.
It seems very artificial to break