Michael Sobolevski smiles at the foot. It’s a foot missing two toes, a bruised foot that survived amputation. And he smiles at the foot’s owner and says something in Spanish. A Russian-born podiatrist living in South Texas, Sobolevskiy takes his time and does his job as if he were caring for a baby. He takes his time examining the waiting room, which is filled with patients who have lost or will soon lose parts of their bodies due to diabetes. Bexar County has the highest rate of lower-limb amputations due to diabetes in both Texas and the United States each year, at 69.9 per 100,000 hospital admissions.
One morning in May, Jose Resendez arrived at the University of Texas Diabetes Institute clinic for a routine checkup after surgery for an ulcer on his right foot. He has only three toes left on his right foot. He’ll be on antibiotics for four weeks and must wear special shoes to protect the wound. Away from the doctor’s prying eyes, he’ll change into formal shoes for a few hours to accompany his preteen daughter to a school dance. “Don’t tell the doctor I took my shoes off,” he says mischievously as he poses for a photo.
Sobolewski, a man with a full head of hair and a thick beard, fits Resendez with a skin-cleaning device that opens a window into his bone. “Patients sometimes have cuts and wounds and don’t even know they have them,” the doctor says. “Those wounds can get infected and require antibiotics and surgery. In most cases, amputation isn’t necessary, but patients often don’t know how bad it is, and by the time they come into the clinic, we have to fight the infection and try to save the leg.”
In the United States, amputations have doubled since 2009, especially in the black community. Hispanics face several challenges in the face of this disease, including low rates of health insurance coverage, unfamiliarity with the healthcare system, high levels of medical distrust, and language barriers. 80% of surgeries to remove toes, feet, and legs are due to complications from diabetes. According to a study by the American Heart Association, Hispanic patients tend to seek medical assistance only when the disease is already advanced. Many are informed of amputation at their first appointment when they have no other options.
If you look at a map of diabetes in the country, the darkest spots are in the South. The number of cases in Texas is already a concern, but it’s even more alarming in Bexar County, which includes the city of San Antonio. According to the San Antonio Metropolitan Health Department, just over one in ten residents of the county, which is close to the Mexican border, have been diagnosed with diabetes. Seven out of 10 amputations in Texas are performed in Bexar County, about 2,000 of them annually. Mortality rates also increased by 40% between 2018 and 2021. The county with the highest number of diabetes deaths in the United States is San Bernardino, California, with Bexar County in second and the Bronx in New York in third.
For anyone with a family history of diabetes, taking care of yourself is important. Resendez’s father had diabetes; so did his grandmother, uncle and other family members. His first wife died of cancer, and he raised his children. He remarried 10 years ago. He lives with Gabriela and their 10-year-old daughter, and he chaperones her to school dances and sports games.
Immigrant and not white
Dr. Sobolevskiy was born and raised in Russia. Upon arriving in the United States, he studied at Austin and the William M. Scholl College of Podiatric Medicine in Chicago. He worked in various hospitals across the country, but it was in San Antonio that he noticed the sheer number of people with diabetes. He completed his residency at University Health, where he is still today, 10 years later.
“How much diabetes affects people, it affects their personal life, their professional life, their quality of life. A lot of these patients are immigrants. Immigrants who are not white, like me, who have to be able to walk, drive, use their legs, it’s really hard,” he says passionately. Many of his patients work in low-quality jobs, working cash. If they don’t go to the hospital, they don’t get paid. “We do everything we can to help them get back on their feet and provide for themselves and their families.”
Resendez doesn’t have health insurance, and Sobolewski doesn’t charge for his consultations. Sobolewski knows Resendez has to work to pay for rent, food, and car insurance. In these cities, there aren’t even safe sidewalks to walk on. He’s just one example of a staggering statistic: one in three men with diabetes suffers from the condition as do women. The average age of patients at the clinic is 30-40 years old, compared to 50-60 years old a decade ago. Sobolewski now sees minors between 12 and 16 years old, essentially children.
Resendez was diagnosed with diabetes at age 36. He suffered from extreme thirst and tried to quench it by drinking as much water as he could. He went to the bathroom 12 times a night and couldn’t sleep. Shortly after his diagnosis, he began to feel better. His cravings for sweets and Coca-Cola returned. After 15 years, doctors were able to save his foot, but three toes had to be amputated. “The only thing I was paying attention to was my blood sugar, I was careless and I wasn’t taking any medicine,” he admits.
The disease began to take an increasingly serious toll. “It affects all your organs, and you don’t know it’s there until it’s advanced,” he says. Now he can’t stand up safely, and the slightest loss of balance means he falls on his face. “I don’t have toes, so I have no way to stop myself.” His eyesight has also deteriorated, making him unable to see his cell phone and requiring him to wear glasses to see things in the distance. According to the US Centers for Disease Control and Prevention (CDC), diabetes is the leading cause of blindness in adults.
Patients may lack support networks or be unable to cope with serious injuries on their own. “These barriers make this population more vulnerable to complications from the disease,” Sobolewski explains.
Resendez had no choice but to follow his doctor’s orders: no sugar, no fast food. “It’s not easy, especially since we love sweetbreads, cookies, and things like that. And we love Coca-Cola,” admits the 57-year-old, who was born on the US side of the Mexican border. He is bilingual, with Spanish being his best.
What’s more important after surgery is that patients recover and continue living the best quality of life possible. This includes education on everything from how to manage blood sugar levels to wearing the right shoes for the patient. The goal is to help patients get back to their normal lives with the help of physical therapy and prosthetics.
The bionic leg and the posture of a marathon runner
As a boy, Polo Guajardo played all kinds of sports and worked out until one day, during a quick medical check to join the police academy, the doctor told him he had diabetes. The 19-year-old didn’t take it too seriously. “I didn’t exercise as much as I used to, but I kept eating the same food,” Guajardo says, hands on his jeans. He’s kind, but his gaze is like a security camera. He smiles when he talks about his grandchildren, whose pictures are taped to the refrigerator door. He smiles when he talks about his daughter, and when he explains that at home, his two dogs cry and bark because they just want to be with him.
He has a below-knee amputation of his left leg and wears a prosthetic. “I can’t do everything I used to do, but I haven’t quit my job and I’ve never wanted to quit. I love what I do, so I can keep going,” says the 50-year-old Mexican-Texan. He works at the local prison and is in a good position. He has to review reports, documents, and issues related to prisoners and staff. His schedule is long, like a hospital shift, and he’s away from home at night. He misses his job, but he accepts it.
Now he is strict with his diet and has no sugar in the house. His house has pictures of his grandchildren on the refrigerator and some police handcuffs hanging along with his house and car keys. He also has a well-equipped gym in his backyard. He goes for walks every afternoon and sometimes rides his bike. His prosthetic legs are the latest models made by a manufacturer with a branch in Austin and cost $5,000 to $6,000. But he has health insurance, which many do not. Texas has the highest percentage of people without health insurance in the United States, with 17% of the population (about 5 million people) not having some kind of medical coverage in 2022.
The Texas Diabetes Institute sees between 8,000 and 10,000 patients a year, many of whom are Latino, says Dr. Alberto Chavez Velásquez, an endocrinologist who specializes in diabetes and metabolism at the hospital. He’s worked there for nine years and is Mexican, having been born in the border town of Matamoros, Tamaulipas. “The incidence of foot ulcers and amputations due to diabetes is as high as 2 percent of the general population,” he says.
Most of the amputations occur in San Antonio’s south side, in a neighborhood of single-story homes and modest but lush gardens. Building facades are painted with brightly colored mosaics. The city government, hospitals, and private organizations offer support groups and outpatient clinics. Information about type 2 diabetes is important because it is largely preventable and accounts for about 95 percent of cases in the United States.
Guajardo believes that sexist culture is a major obstacle to prevention: “My parents are from Coahuila, Mexico. Mexicans are stubborn, they don’t care if something hurts. They don’t go to the doctor when they’re sick, but when something bad happens, they’re told they’ll have to amputate their leg. There are a lot of people who don’t want to do that. They choose death, even if it would save their life. Sooner or later, they die, because the infection has a very strong effect on the blood,” he says.
He’s not alone in this view: “It hits you where it hurts most: masculinity,” he confesses, and despite losing three toes, he considers himself “one of the lucky ones” to have kept his feet.
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