Saturday, 25 May 2019

Life and Limb – The Texas Observer

Each diabetic amputation represents not just a personal tragedy, but a failure of the U.S. health-care system.

Veronica G. Cardenas

by Sophie Novack
March 1, 2019

Daniel Zamora still remembers the smell. At first he didn’t realize anything was wrong. A small blister appeared on his left pinky toe where his sneaker rubbed against his skin. He had developed blisters before, but this one wouldn’t go away. First the tip of the toe darkened, slowly turning the jet-black color of his hair. Then the color spread toward the rest of his foot.

He was used to ignoring such things. It was 2016, and Zamora, now 55, had gone his whole life without health insurance. Born in Matamoros, Mexico, he moved across the border with his family to Brownsville when he was about 6 years old. For decades, Zamora, a legal permanent resident, worked maintenance jobs for low pay and no benefits. He couldn’t afford to take time off or see a doctor. Sometimes, when he wasn’t feeling well, he’d brew an herbal tea from the leaves of the moringa tree just outside his front door. He often tried curing his cuts and blisters with ointment or rubbing alcohol. Occasionally, if things got really bad, he reluctantly went to the emergency room, where, he says, doctors made snide remarks about his inability to pay.

So he waited. Maybe it would pass.

Finally, the smell got unbearable. Like road kill in the hot South Texas sun. A couple of months after the blister appeared, Zamora drove 2 miles to Valley Baptist Medical Center, where doctors quickly diagnosed him: His diabetes, uncontrolled for years, had blocked blood flow to his toe, preventing it from healing. What began as a minor blister was now a life-threatening emergency. Zamora says the doctors sent him home with medication to treat the wound, but a few weeks later he went back to the ER, where he had two toes on his left foot amputated to prevent gangrene from spreading up his leg.

diabetes, rio grande valley

Daniel Zamora, 55, was diagnosed with diabetes about 10 years ago. In 2016 he had two of his left toes amputated.  Veronica G. Cardenas

When Zamora found out he had diabetes, about 10 years ago, it didn’t come as much of a surprise. In the Rio Grande Valley, nearly one in three people has the disease, triple the national rate. The Valley is among the poorest and least-insured regions in the country. It’s also overwhelmingly Hispanic, a population that has a higher risk of developing type 2 diabetes.

Perhaps the most visceral indication of the Valley’s diabetes crisis is the shocking number of people living with amputations. The rate of diabetic amputations in the Valley was about 50 percent higher than the state rate in 2015, according to data from the state health agency. In Cameron County alone, where Zamora lives, hospitals recorded 281 diabetic amputations that year. That’s more than 50 percent higher than the national rate, according to the Centers for Disease Control and Prevention. The estimated amputation rate in smaller Willacy County, just north of Cameron, was more than four times the national rate. “Good gracious,” said Ed Gregg, a CDC epidemiologist, when looking at the data. “What’s going on with Willacy?”

When he first found out he was diabetic, Zamora says, he “didn’t pay too much attention to it.” Both of Zamora’s parents died from diabetes, which is the seventh-leading cause of death in the United States. His father used a wheelchair for the last years of his life, after a diabetic amputation above the knee. In the Valley, there’s a fatalism associated with the disease, often considered an inevitable inheritance.

What Zamora didn’t realize is how big an impact a small blister would have on his life. For months after the surgery, he couldn’t walk. Nor could he afford professional wound care, so his son came by each day to change the bandage. Zamora had to quit his job cleaning a nearby gym because it required him to be on his feet and lift heavy weights. Along the way, he racked up about $100,000 in medical bills, which he’ll never be able to pay. When he developed an ulcer on his other foot, he went to see a doctor in Matamoros, because it would be cheaper. Finally, last summer, Zamora’s disability qualified him for Medicaid and Medicare.

When I ask how he’s doing, Zamora’s typical response is: “surviving.” He’s frustrated that he had to wait until he was very sick and couldn’t work to get health coverage from the government.

“Being diabetic is real bad…” Zamora’s voice trails off. “A lot of people die from it.”

He’s adjusting to life as an amputee, but he still loses his balance, wobbling “like an egg” when he walks. That, along with vision problems due to the diabetes, makes manual labor difficult. But without a high school diploma, he has few job options. For now, Zamora is surviving on a disability check that’s even less than the $1,300 a month he made at the gym.

It’s a story told over and over again in the Valley: You don’t know you have diabetes until it’s severe, because you rarely see a doctor. You get a cut or blister but ignore it, because diabetes-related nerve damage means you can’t feel it, or you’re too busy working or taking care of your family to go to the doctor. The wound gets infected. By the time you get help, the infection is so bad that amputation is necessary. You can’t afford proper care, so sometimes the wound gets infected again. You get another amputation.

Diabetic amputations have a domino effect on the lives of patients and families. It begins with the patient exiting the workforce, sometimes decades early, “which creates every complication we can think of,” said Belinda Reininger, regional dean at the UTHealth School of Public Health in Brownsville. “The family’s economic situation is negatively impacted; children may have to start working and supporting their parents, slowing or putting aside their educational attainment goals. … We’re already an area known for living $20,000, $25,000 below the median income of the state — to lose your wage earner is just tremendous. That’s at the family level; you magnify that to the society level and it continues to ripple.”

Each diabetic amputation represents not just a personal tragedy, but a failure of the U.S. health-care system. The epidemic also suggests a possible future for the rest of the country, as the Latino population booms and health officials grapple with how to get diabetes under control. The number of adults diagnosed with diabetes in the United States quadrupled between 1980 and 2014. CDC researchers now project that the number will nearly triple by 2060.

A new study published in Diabetes Care in November found that following a two-decade decline, the rate of diabetic amputations nationwide increased in recent years, especially among young and middle-aged adults. Gregg, who worked on the study, told the Observer that though diabetes care overall has improved, the “alarming” findings are a “wake-up call.” He says amputations are important indicators that something went wrong with diabetes management, because they’re generally preventable in patients who can acce