During my initial visit to Dangriga, I asked a prominent Garifuna physician for feedback on my proposed project. He urged me to focus on diabetes and its many chronic complications instead of parasitic worms. He also offered to mentor the project if I came back to spend a year in Belize, getting to know people who were interested in being interviewed about their experiences and trying to learn something about the ways they were making sense of what was happening.
Many doctors worldwide are also confused by the ways diabetes is now changing. Type 1 (about 5 percent of the world’s cases) used to be commonly called “juvenile diabetes,” while more gradually developing type 2 was labeled “adult onset diabetes” (about 95 percent of cases). They are both rising steeply. Over one million children and teenagers worldwide are now estimated to have type 1 alone.6 But today, more children are also developing type 2, and more adults type 1. In untreated versions of either type, high or low blood sugar wears on the blood vessels carrying it. These vascular complications can accrue into severe injuries over time, including organ damage and limbs with circulation so limited that even tiny ulcers might end in amputation. Some researchers today propose to frame types of diabetes instead more like gradations on a spectrum, offering new labels: severe autoimmune diabetes; severe insulin-deficient diabetes; severe insulin-resistant diabetes; mild obesity-related diabetes; and mild age-related diabetes.7 Many of the first people I met in Belize, though, simply called it all sugar. I framed this project’s scope accordingly.
By the time I returned to live for a year in southern Belize in 2009–10, I had read everything I could find about diabetes. There was an odd dissonance between the tenor of U.S. public health conversations at the time, where the topic was still often assumed to be minor background noise, and statistics I could not really fathom. For instance, the International Diabetes Federation estimated that diabetes annually killed more people worldwide than HIV/AIDS and breast cancer combined.8 Somehow, I typed abstract numbers over and over into research proposals back then without grasping the implication that a significant number of the people I was getting to know were going to face untimely deaths.
This book is set in Belize, but it also signals a global story. Diabetes takes specific shape in each life, family, and nation—but it’s also spreading and causing unevenly patterned injuries and deaths in nearly all countries in the world today. Belize was dealing with the situation about as well as a very small country with limited resources initially could manage. Most health workers and policy makers I encountered in Belize cared greatly about trying to address the rising issue of diabetes. The uneasy scenes in this book show just how complicated a global problem diabetes is—even for a small country labeled “middle income” by the World Bank’s relative standards, where so many community leaders and caregivers are working hard to respond. Many health officials and doctors in Belize actively encouraged critical dialogue, and were trying to expand discussions about the next steps against a growing epidemic in which their offices and many others have some role to play in future policies. But the fact is that the food systems and agricultural toxicities contributing to diabetes are domains far beyond the purview of any Ministry of Health alone. Even the wealthiest governments in the world have not managed to bring diabetes under control.
National headline, August 2010.
Belize is so beautiful that its reputation as a vacation spot for Europeans and North Americans can saturate even academic visions and distract from serious life struggles. The country’s name often brings cruise ship brochures to mind. But many citizens, of course, also struggle with material constraints and social issues similar to those in neighboring countries, as much careful anthropology in Belize has shown.9 Still, I have received enough questions over the years from audiences who have not taken social struggles in Belize seriously that it is worth reprising a thumbnail sketch of resource context: Belize is somewhere toward the lower economic range of countries in Latin America and the Caribbean. It is among the countries where the average income is more than four thousand dollars but less than five thousand dollars, according to World Bank estimates of GDP per capita in 2016. For a sense of regional reference, the other five countries listed in that income range include Jamaica, Guyana, El Salvador, Guatemala, and Paraguay.10
The Stann Creek District has the highest rate of diabetes in the country, nearly double the national average.11 I talked with all kinds of people across Belize’s tiny and diverse population. But as I began to be introduced to families dealing with diabetes, I ended up meeting a disproportionate number of Garifuna people (more properly, in plural, Garinagu). Both Black and Indigenous,12 Garinagu make up some 5 percent of Belize’s overall population but represent the majority of residents in Dangriga. They number among the world’s surviving speakers of a Carib-Arawak Kalinago language and widely consider themselves a “nation across borders,” as Joseph Palacio puts it,13 with thriving communities across Guatemala, Honduras, Belize, Nicaragua, and U.S. cities from New York and Los Angeles to Chicago. “Certain diseases are known to have high incidence among the Garinagu relative to the wider population,” the National Garifuna Council (NGC) of Belize wrote in its statement on health. “These include diabetes, hypertension, hepatitis, cataracts, and glaucoma. There is urgent need for studies to be carried out as well as the provision of treatment.”14
Wading with patients across washed-out roads knee deep in mud to keep doctor’s appointments, or traveling by canoe alongside everyone else when Tropical Storm Arthur washed out Kendall Bridge (which cut off the single road that linked southern Belize to the rest of the country and its only tertiary care hospital), I saw how realities often labeled “environmental” in the keywords of an academic journal were already part of the terrain that people with diabetes were negotiating in life. Nurse Suzanne recalled floating from rooftop to rooftop a few days after Hurricane Iris to deliver diabetic pills and insulin. The rough boat ride through floodwaters made her seasick, but she had heard how many families—on nearly every rooftop—had at least one person going into a coma or other diabetic emergency on top of their houses.
Once, I rode through the Maya Mountains in the back of a slow-moving ambulance with Paulo and his young daughter Elisa, wondering about tipping points. Elisa’s pharmaceutically induced high blood sugar was a secondary concern to the fact that her skin was “coming unglued,” which may also have been a side effect of the steroid medicines. We never knew for sure. There was no IV rack, so Paulo and I took turns holding the bag until our arms shook. None of us had been inside an ambulance before. We had imagined speeding to Belize City, but instead we told each other jokes about wishing bus drivers would travel this slowly along the precipitous highway.
Years later I followed behind Paulo as he chopped dense jungle plants away to clear Elisa’s grave, the surrounding vegetation’s growth a ruthless account of the years I had been gone. I have never felt more responsibility than when I learned that her mother, Angeline, had waited three years for me, and together we made the trip to see her daughter’s grave for the first time. Afterward, Angeline handed me a photo of herself kneeling with open arms as Elisa took her first baby steps. The fact that the picture’s chemical exposures had outlasted Elisa’s seemed to dissolve all the words we tried to say. I gave them an image in return, an ornament engraved at a Pennsylvania Christmas shop. They cut the ribbon off and nailed it to the dash of their pickup truck.
Elisa’s real name is written on that ornament, but not in this book. One difficult decision in finalizing this project was that most of its contributors requested that I use their actual names. “But then it wouldn’t be true,” one research contributor protested, when I asked for her input choosing a pseudonym. Others did prefer to create new names, as Belize is such a small place.15 For this reason, I have mostly