"100 million limbs are at risk of amputation!"

Diabetes in India: A Sandal Scandal

"India will have 50 million diabetics by 2010. Close to 20% of all diabetics have some form of amputation and surveys indicate that 60% of these amputations are because of wrong or no footwear" said Mr. Vijay Viswanathan, Managing Director of the MV Hospital for Diabetes. Although he was referring to unpublished data which was likely somewhat exaggerated, India is becoming the diabetes capital of the world.

During the first week of November when Diastep was launched, a new Indian sandal for low-risk diabetics to prevent foot ulcers and ultimately amputations, I happened to spend a morning at a rural diabetic foot clinic with a physical therapist.

In 150 minutes, we examined 47 patients with diabetes for cracks, callouses, corns, bunions, ulcers, tingling, burning, loss of sensation, and other risk factors for nerve damage, infection, and amputation. The only thing that slowed us down was when the electricity went off and we had to use the light from our cell phones to examine people's feet. That morning I saw the rigor of village life emblazoned on the feet of dozens of farmers, coolies, animal herders, and other rural folk. All the patients had their pre-breakfast glucose checked and they were surprisingly high across the board. My colleague commented on the "post-Diwali glucose surge" (Diwali is the Indian festival of lights where people eat copious sweets with friends and family).

That same afternoon while making a home visit to a patient with HIV/AIDS, we passed a man on the street who the hospital had distributed a tricycle to after he lost his leg from diabetes.  I asked him if I could take his picture and use it to educate others about what can happen in late stages of poorly managed diabetes and he obliged. Mr Subramaniam of NK Pallayam village, featured in the photo below, stated "It started out as a blister on my foot, before I knew it I had to get a below the knee amputation. I didn't take my medicines so things got worse and I had to have an above the knee amputation." His message to other diabetics is "I suffer so you better take care of your diabetes so you don't suffer too. This happened to me because I was careless."

In an attempt to meet the needs of (and profit from) the millions of diabetics in India, Diastep was launched through a collaboration between the MV Hospital for Diabetes, its research wing the Diabetes Research Center, the Novo Nordisk Education Foundation, and the Central Leather Research Institute.

Its special design features address issues such as pressure distribution on the foot, grip, traction, comfort and durability to prevent foot ulcers and infection. “We have the best medical technology in the world but very poor access. Affordability and access are the primary concerns which have to be addressed,” said T. Ramasami, Secretary, Department of Science and Technology, IIT-Chennai. Although such important issues were discussed at the launch, they have yet to be addressed.

At a starting price of 1,350 rupees a pair ($35 USD) who can afford Diastep? None of the 57 villagers I saw that morning at the diabetic foot clinic, most of whom earn less than $2 dollars a day, could afford Diastep.  Mr. Subramaniam, featured above, couldn't even afford a Diastep for his remaining left leg. He lamented to me, his inability to pay for his insulin injections which totaled less than 500 rupees per month.

Diastep should have hired a cultural anthropologist to assist in marketing and distribution because amputations and special sandals have a long history in India.  I learned that earlier models of the MCR Chappals marketed for diabetics faced resistance from some local people since they were worn by people with leprosy in the past who had peripheral nerve damage and amputations. Perhaps more important than the stigma of special footwear, is the need for gradated pricing and social marketing to the lower socioeconomic classes. My colleagues who work with diabetics told me the on-the-ground reality: many elderly aren't used to wearing shoes, farmers don't like to wear them when they're wading through their fields, and most models are too costly.

Although the multidisciplinary research collaboration to create Diastep was exciting and impressive, is it simply another example of an Indian innovation that will never reach the average Indian? Time will tell if it is really a technological "feet" or a sandal scandal.

Watch a video of the launch of Diastep below set to classical music: