[Bruinrab]

Diabetes, though, ruins sensation in the legs, and foot infections go undetected and are often a preamble to amputations. So doctors like Dr. Ramachandran strongly recommend against going barefoot. Yet the culture demands precisely the opposite.

Seeking a middle ground, Dr. Ramachandran presses his patients to don what he calls Temple Socks during worship. They are made at his hospital, conventional socks with rubber bases stitched inside. They are a slow sell.

Dr. Vijay Viswanathan, the hospital’s joint director, gives patients stickers to affix to their bathroom mirrors: “Take care of your feet.” Like doctors elsewhere, he promotes custom shoes. He drifted into them because of leprosy footwear.

Leprosy damages feet and requires special shoes, with tougher undersoles and without nails or sharp edges, that also suit diabetics. But when the diabetics in the telltale footwear appeared at restaurants, they were shooed away, thought to be lepers. So now the hospital makes distinctly different designs.

The consequences of the diabetic foot can be grim. While the affliction knows no class distinctions, the solutions do.

In his lectures, Dr. Ramachandran recounts the case of an impoverished diabetic with a hideously infected leg. Unable to find medical care, he laid the leg across the railroad tracks. The next train to hurtle past did the surgery.

For a limb replacement, the very poor may make do with a $50 wooden leg that does not bend. A woman like Mrs. Chitrarangarajan, 49, who runs a school for the autistic and is married to an oil executive, opts for the best. Her right leg was surrendered to diabetes in 2001. She found a German leg for $6,000 and ordered it over the Internet.

S. P. M. Ameer owned a shoe store when diabetes befell him 30 years ago. Soon, circulatory problems attacked, he closed his shop, he lost his wife, then his leg last January.

Now, at 58, occupying a mirthless room in a cheap hotel on a rackety side street, he no longer recognized the solemn shape of his life. He rarely left his squalid room. “Who hires a man without a leg?” he asked.

He had yet to arrange for a prosthesis. He had no way to pay for one. “God has to apply,” he said.

These stories circulate. But the cultural imperatives hold strong. Even in the sugar hospitals, with admonishments plastered on the walls, some patients insouciantly stride about barefoot. Directly outside the office of one local sugar doctor, beside a sign preaching against the perils of bare feet, another sign notified patients to remove their shoes before entering. And so, barefoot, they sat before him and heard him lecture them not to go barefoot.

Sick Without a Safety Net

Krishnasamy Srinivasan, 66, did not look good. He rarely did anymore. He was recumbent in a hospital bed, his shirt off, his eyes underslung with bags. He had come in by train for another checkup. He now lived deep in the suburbs, where it was cheaper, part of the sad new mix of his life.

He had done very well as a textile exporter, came to own four homes, and enjoyed rental income from those he did not occupy. Then diabetes hit when he was 40. He paid it little mind as it marinated inside his body. Over the last 15 years came heart problems and the need for bypass surgery. His kidneys deteriorated. He is now on dialysis.

He held up the needle-marked right arm of his malfunctioning body, identifying it as “my dialysis arm.”

He had to stop working. To cover the medical costs, he sold three of the homes. His family has been living off the evaporating proceeds, their past irreclaimable.

Diabetes is bankrupting people in the country, often the reasonably well off, and mainly because of a lack of insurance.

Few in India have health insurance, and among those who do, policies generally do not cover diabetes. Middle-class diabetics often exhaust a quarter or more of their income on medications and care. Instances abound where the sick must sell their possessions and compress their lives to feed the diabetes maw.

S. Kalyanasundaram, the chief regional manager in charge at the Chennai office of the National Insurance Company, one of the country’s biggest, explained that the issue with insurance was the odds. “Insurance can only work if the law of averages applies,” he said. “There are too many people with diabetes.”

Some concepts are easy to sell in India, Mr. Kalyanasundaram said, but health insurance is not one of them. “The capacity to pay is not there,” he said. “And many people take disease as a God-given thing to just accept. So why buy insurance?”

Things are beginning to change, even the possibility that policies may cover diabetes for an appropriate premium, but who knows how much they will change? Mr. Kalyanasundaram mentioned that certain preferential customers merited customized policies with an unorthodox clause. If they have diabetes and claim no expenses for four years, then afterward their diabetes will be covered.

“We are testing a belief,” he said. “We think it possible that if diabetes doesn’t manifest in those four years, then it will not manifest in the future.”

It was an odd thought for a disease that usually worsens with time. As for the results, he said it was too early to know how the test was going. “We are still testing.”

With many things it is still too early in India. And so rural dwellers often cope with unavailable or inaccessible health care, frequently relying on unlicensed doctors, many knowing little, if anything, about diabetes. Diabetes researchers estimate that three-quarters of those stricken with the disease in rural villages do not know they have it.

In urban areas, the sick, other than the poorest, prefer to bypass beleaguered government hospitals and seek private care. But without insurance, the cost of a long-term illness can be crushing.

Mr. Srinivasan’s wife, Srinivasan Muthammal, 61, also has the sugar, but not its complications yet. Like her husband, she is overweight. As she listened to him talk of their black hours, her face was frozen.

“We are angry with the god,” she said. “You gave us four houses in four directions and all the wealth, and now you have taken it all away. Why?”

Mr. Srinivasan suggested they had cash for one more year, perhaps a little more.

“I’m angry with the diabetes,” he said. “You are a pauper all because of the sugar.”

Till Diabetes Do Us Part

Divorce is rare in India, but in these changing times it is very much on the upsweep. Diabetes, here and there, even figures in the marital strife. Women may be stigmatized. Men find themselves impotent and then newly single.

K. Sumathi, a Chennai lawyer who sometimes deals in the accelerating number of divorces, appreciates the impact of diabetes in a country where different centuries breathe side by side.

She said a young woman with diabetes, for example, is often deemed damaged and unmarriageable, or must marry into a lower caste. Indian law recognizes five broad grounds for divorce, one being if either spouse acquires a chronic disease. Diabetes can rapidly debilitate a breadwinner and impose impotency, either outcome a solid marriage wrecker.

She told the story of a recent case: A wife, living as custom has it with her in-laws, said the stress of the circumstances contributed to her getting diabetes. She wound up in a diabetic coma and had to be hospitalized. Her husband, a dentist, chose to attend to cavities rather than visit her. The divorce was completed seven months ago.

There was also the account of a husband who accused his unhappy wife of sneaking extra sugar in his tea, hoping he would acquire diabetes and die. It proved to be a poor concept. He survived. The marriage did not.

J. Vasanthakumari, a marriage counselor who is friendly with Ms. Sumathi, said she has seen the disease percolate in the back stories of some of her clientele. Diabetes. Then sexual dysfunction. Unhappiness. Appointments with her.

“You must understand one basic thing,” she said. “People in personal matters will not bring diabetes to the surface. But women tell me, ‘He’s not affectionate, he’s not taking care of me, he’s not like before.’ It’s the diabetes.”

She went on: “Sometimes someone gets diabetes partly because he’s an alcoholic. The marriage falls apart. The real reason is the alcoholism. But the diabetes becomes the last straw on the camel’s back.”

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