Michael Sobolevksy smiles at a foot, a foot without two toes, battered, a foot that has been saved from being amputated. And he smiles at the owner of that foot and says a word in Spanish. Sobolevksy, a Russian-born podiatrist now in South Texas, takes the time and patience to do his job as if he were caring for a baby. Although he has a high number of patients waiting, almost all working-age men of Latino descent, who have lost—or will soon lose—a body part as a result of diabetes. Year after year, Bexar County, which includes San Antonio, has the highest rate of lower limb amputations due to diabetes in both Texas and the United States, 69.9 per 100,000 hospitalizations.
One morning in May, José Reséndez arrives at the University Health Diabetes Institute clinic for routine healing after undergoing surgery for an ulcer on his right foot, which supports three heroic toes. He must take an antibiotic for four weeks and not remove a special shoe to protect the wound. Far from the eyes of the doctors, he will put on his formal shoes alone for a few hours to accompany his preteen daughter to a school dance. “Don’t tell the doctor I took off my shoe,” he says with a mischievous face when he poses for photos.
Sobolevksy, thick hair and dark beard, places a device to clean the skin that opens a window to Reséndez’s bone. “Patients can have a cut, they can have a wound and not even notice it,” says the doctor. “That wound can become infected, they need antibiotics, they need surgery, most would not need an amputation, but many times they don’t know how bad it is and, when they come to the clinic, we have to fight the infection and try to save the foot ”.
Amputations have doubled since 2009 in the United States, especially in black communities. Latinos face several disparities in the face of the disease: a low percentage of health insurance, little familiarity with the care system, high levels of medical mistrust and language barriers. 80% of surgeries to remove a finger, foot or leg are due to complications with diabetes. An American Heart Association study showed that Hispanic patients tend to seek medical help later, when the disease has already advanced. Many receive the news of an excision at the first visit to the doctor, when there is no other option.
If you look at the map of diabetes in the country, the most intense color is in the south. And if the number of cases in Texas is already worrying, it is even more alarming in Bexar. Just over a tenth of the residents of this county, which is near the border with Mexico, have been diagnosed with the disease, according to the San Antonio Metropolitan Health District. Seven out of every ten amputations in the State are performed here, about 2,000 each year. The mortality rate also increased by 40% between 2018 and 2021. The county with the most deaths from diabetes in the United States is San Bernardino, in California; Bexar is the second, and the Bronx, in New York, the third.
When a person has a family history of diabetes, care is essential. Reséndez’s father had diabetes, as did his grandmother, his uncle and other relatives of his. His first wife died of cancer and he raised their children. Ten years ago he remarried. He lives with Gabriela and her 10-year-old girl, with whom he goes to dances and whom he accompanies at her sports games.
Migrant and non-white
Dr. Sobolevsky was born and raised in Russia. Upon arriving in the United States he studied at Austin College and at Medical School in Chicago. As a student he worked in different hospitals around the country, but in San Antonio he noticed the enormous number of diabetes cases. At University Health he started as a resident and he is still here, a decade later.
“You see how much diabetes impacts people, it affects their personal and professional lives, their quality of life. Many of these patients are immigrants, just like me, immigrants who are not white, who have to be able to walk, drive, use their legs, it really hurts,” she says passionately. Many of his patients have jobs in rough trades and work for cash. If they don’t go, they don’t get paid. “We do everything possible to get them back on their feet so they can provide for themselves and their families.”
Reséndez does not have health insurance and Sobolevsky will not charge you for this consultation. The doctor knows his reality: he must work to pay for rent, food or car insurance, which are necessary in these cities where there are even no sidewalks for safe walking. It is one more case of an overwhelming statistic, for every three men with diabetes, one woman suffers from the disease. In the offices the average age is 30 and 40 years old, a decade ago the majority of patients were 50 to 60. Sobolevsky now sees kids from 12 to 16 years old, practically children.
Reséndez was diagnosed with diabetes at 36. He developed a terrible thirst that he tried to quench by drinking water, water, water. He went to the bathroom up to 12 times a night and couldn’t sleep. Shortly after the diagnosis, he began to feel better. He returned to sweet cravings and Coca Cola. 15 years later they were able to save his feet but three toes were removed. “The only thing I took care of was my sugar levels, I was careless, I didn’t take my medicine,” he admits.
The disease began to rage a little more. “It attacks all your organs, you don’t realize it until it’s advanced.” Now she can’t stand safely, if she loses her balance even a little she will fall flat on her face. “You have no way to stop anymore because you don’t have those fingers.” He has also been losing his vision, he can’t see his phone and he uses glasses to see far away. Diabetes is the number one cause of blindness in adults, according to the Centers for Disease Control and Prevention (CDC).
Sometimes patients do not have support networks nor can they take care of themselves even if they have a deep wound. “Those are the barriers that keep this population more susceptible to the complications of the disease,” explains Sobolevsky.
Reséndez has no choice but to follow the doctor’s instructions. No sugar or fast food, none of that. “It’s not easy, especially because we love sweet bread, cookies, things like that. We love Coca Cola,” admits this 57-year-old man who was born on the border on the United States side. He speaks two languages, but is most comfortable with Spanish.
The most important thing after surgery is to try for the patient to heal and be able to continue with their life with the highest quality possible. This involves educational work, from how to manage sugar levels to how to coordinate so that they get adapted shoes. The goal is to try to get them back on their feet, with physical therapy or prosthetics.
Bionic leg and marathon runner attitude
When he was a boy, Polo Guajardo did all kinds of sports and training, until one day he arrived to take a simple medical exam to enter the police academy and the doctor told him the news: diabetes. He was 19 years old and didn’t take it very seriously. “I continued eating the same thing even though I didn’t exercise as much as before,” says Guajardo, with both hands on his jeans. He’s kind, but his gaze is like a security camera. He smiles when he talks about his grandchildren; he has their drawings taped to the refrigerator door. He smiles when he talks about his daughter. And he smiles when he explains that his two dogs cry and bark because when he is home they only want to be with him.
His left foot was amputated from the knee down and he wears a prosthesis. “He can’t do everything he did before. But I don’t stop working, I have never wanted to get out of working. “I like what I do, that’s why I keep going,” says this 50-year-old Texan of Mexican descent. He works at a local jail and has a good position. It is his turn to review reports, papers, things of the prisoners and the staff. His hours are like hospital guards, long hours and nights away from home. He misses the action, but resigns himself.
Now he is strict with his meals. He doesn’t have sugar at home. His grandchildren’s drawings on the refrigerator, some police handcuffs hanging along with the keys to the house and his car. Also a well equipped gym in the back yard. He goes for a walk every day in the afternoon and sometimes rides a bicycle. His biotic leg is modern, from a manufacturer with a branch in Austin, and costs between $5,000 and $6,000. But he has health insurance; There are those who don’t. Texas has the highest rate of people without health insurance in the entire country; in 2022, 17% of the population lacked any type of health protection (almost five million people).
The Texas Diabetes Institute serves between 8,000 and 10,000 people a year and a large proportion is of Latin origin, says doctor Alberto Chávez Velázquez, an endocrinologist specialized in diabetes and metabolism at the same hospital. He has been working at the institute for nine years and is Mexican, born in the border city of Matamoros, Tamaulipas. “The incidence of diabetic foot, ulcers and amputations is as high as 2% of the general population,” he confirms.
Most of the amputation cases are in the southern area of San Antonio, neighborhoods of low houses and modest but flourishing gardens. The facades are a mosaic of intense colors. The city government, hospitals and civil organizations have support groups and outpatient clinics. Information about the disease is key because type 2 diabetes is largely preventable and accounts for nearly 95% of diagnoses in the United States.
Guajardo believes that the sexist culture is a big barrier to prevention. “One as a Mexican… I am not Mexican. Well, I’m Mexican. The only thing that tells me that I am American is that I was born here. My parents are from Mexico, from Coahuila. Mexicans are stubborn, we don’t pay attention if something hurts us. If we feel bad, we don’t go to the doctor. But then the bullshit comes, they tell you that they are going to amputate your foot, and there are many people who don’t want to, even if it’s going to save your life, they prefer to die. Sooner or later… rather sooner, they die, the infection has a very strong effect on the blood,” he says.
He is not the only one who thinks like that. “It hits you where it hurts most, in your manhood,” Reséndez confesses. He, without his fingers, is still considered “a person” for keeping his legs.