Traveling with Sugar: Chronicles of a Global Epidemic by Amy Moran-Thomas (review)

Amy Moran-Thomas's Traveling with Sugar is a luminous ethnography about living with diabetes in Belize. Together with homicide, diabetes is one of the top causes of death for adults there. By Moran-Thomas's telling, diabetes is a no less violent death for being slower than murder. She opens by describing a photo album shared by a research subject, which records not only the family's joys, but also significant loss. Moran-Thomas sees "loved ones changing in photograph albums. Missing limbs, failing organs. An empty dress left hanging to outline an absence" (p. 5). In fact, "Missing body parts were often central to how they told stories and measured time" (p. 27), she writes. The disease "eludes any single, self-evident image," even though "traces of diabetes were everywhere in Belize" (p. 4). This reminded me of Roland Barthes' words in Camera Lucida: "The Photograph is violent: not because it shows violent things, but because on each occasion it fills the sight by force, and because in it nothing can be refused or transformed (that we can sometimes call it mild does not contradict its violence: many say that sugar is mild, but to me sugar is violent, and I call it so)."¹ Moran-Thomas illustrates Barthes's point by describing how people's bodies archive the violence of sugar and the economic, environmental, and racial systems that have produced it. She shows that the "slow violence" of diabetes has a counterpoint in the form of "slow care" (pp. 25, 284). Even though, to paraphrase Barthes, it often seems that nothing can be refused or transformed for her research subjects, Moran-Thomas resists tragedy by attending to people's capacity for "extraordinary survival" and mutual aid (p. 47).

Based on fieldwork in diabetes clinics and at people's homes, Moran-Thomas focuses primarily on people of indigenous and African descent, known regionally as Garifuna, whose transnational community stretches across the Caribbean and the United States. The book's significance goes far beyond Belize and Garifuna, though. She makes a compelling case for thinking differently about diabetes as a multidimensional public health problem rooted in histories of colonialism, racism, dispossession, and environmental disruption. Moran-Thomas rejects popular narratives associating diabetes with individual ignorance or gluttony, instead showing that it is enmeshed in more complicated patterns of scarcity and excess. How, for example, can we explain that "parts of Belize have some of the highest rates of diabetes in the world without having a single corporate fast-food chain" (p. 124)? She notes that widespread pesticide use contributes to rising rates of diabetes since these chemicals act as endocrine disruptors (pp. 38, 74, 111). She challenges "the fatal fictions of 'noncompliance,'" showing that people intentionally reject medical advice and prescriptions (including insulin) when they are ill suited to lived realities (p. 21). In fact, most people have access only to "fragments of care" that rarely converge towards healing (p. 171).

She argues that the traumas of colonialism, racism, and poverty are significant to disease etiology. Indeed, Belize is shaped by the sugar industry's "far-reaching material legacies" (p. 31). Some are obvious—abandoned locomotives, mills, furnaces, and sugarcane fields. Other legacies are less visible. Recent theories of epigenetics suggest that "historical and ongoing atrocities and persistent inequalities" can "have material effects on ever-changing human biology, even at the cellular level" (p. 213). Other colonial legacies include dependence on imported processed foods and scarcities of lifesaving medicines, machines, and specialists. In one telling example, Moran-Thomas explains that in Belize's tourism-dependent economy, foreign scuba divers have nearly exclusive access to hyperbaric chambers that could be used to preserve limbs among diabetic Belizeans (pp. 82–83). In another example, people sell land to tourism developers to pay medical bills. Diabetes is literally a tool of dispossession, truncating stable access to healthy food, shelter, and generational legacies (p...