Indigenous Mexicans With Diabetic Foot Face Delays in Care

In rural areas of Mexico, Indigenous patients with diabetes who have few economic resources face obstacles that delay proper care. Patients with complications of diabetes such as diabetic foot are in an extremely vulnerable situation compared with other population groups.

In addition, structural barriers inherent in the administration of health systems sometimes make Indigenous people with diabetes and pain “invisible.” Neither epidemiological registries nor official health reports provide detailed information about the health of these patients.

When data on the ethnicity of these patients are available, they are often based on the “speaking Indigenous language” indicator. The most appropriate reference for defining ethnicity, however, is self-registration, according to international regulations.

These conclusions stem from a qualitative-quantitative analysis of inhabitants from six Tlacolula valley communities in Mexico. The multidisciplinary team of experts who led the analysis emphasized that, despite the increased incidence of diabetic foot in Mexico (a problem that is a leading cause of premature death and limb amputation due to nontraumatic factors), little is yet known about its impact on Indigenous populations.

Mexico has high social inequality and high incidence rates of diabetes. In their scientific report, the researchers emphasized that “in Mexico, there is little information about this disease, its peripheral circulatory complications, and diabetic foot in this population group.” This lack of information partly results from “historical invisibilization of health needs of Indigenous communities, as well as the institutional tendency to rule out collection of health data on the basis of ethnicity, based on the idea of fairness and nondiscrimination, a tendency that has begun to change especially over the last decade,” they wrote.

From a clinical and epidemiological perspective, the authors added, little is known about the impact of diabetes on Indigenous populations. It is important to describe various aspects of the patient’s experience with this disease, which leads to vascular complications in addition to diabetic foot.

Inadequate Infrastructure

Hence, the researchers conducted the current work, which is based on 12 surveys of health staff in the region, 11 in-depth interviews of affected persons, and, for the quantitative part, the analysis of diabetes information and complications that has been made public by the Federal Health Secretary.

“The main motivation to focus our research on diabetic foot complications in Indigenous populations was the direct and visible impact it has on patients’ quality of life, in addition to the high prevalence of nontraumatic amputations in these communities,” Laura Montesi Altamirano, PhD, a social anthropologist at the Center for Research and Advanced Studies in Social Anthropology (CIESAS) South Pacific Oaxaca, of the National Council of Humanities, Science and Technology, told the Medscape Spanish edition.

Diabetic foot, unlike other complications such as cerebrovascular disorders or renal failure, has an immediate and devastating effect on mobility and autonomy, said Montesi Altamirano, who specializes in the study of health and disease processes. “Amputations cause disabilities that not only limit the ability to work and move around but also result in great emotional and psychological distress for patients and their families, especially in rural settings where support networks are limited and financial resources are scarce.”

The lack of adequate infrastructure and the shortage of trained rural medical staff significantly contribute to diabetic foot progression in these communities, she added. “The difficulty in accessing follow-up consultations and the absence of health education programs focused on prevention exacerbate amputation rates, which could be avoided with preventive measures and timely care.”

The researchers acknowledged that there are insufficient data to state conclusively whether the prevalence of diabetes in the Indigenous population is high or low, compared with the rest of the country. But ample evidence indicates that this population has poorer health indicators, as well as poorer access to healthcare services, “especially when ethnicity intersects with low levels of education and income, migratory status, nonaffiliation with health institutions, and residence in rural areas.”

Based on data from the National Health and Nutrition Survey 2022, the prevalence of diagnosed and undiagnosed diabetes in Mexico’s general population has been estimated to be 12.6% and 5.8%, respectively. These estimates result in a total prevalence of 18.3% (ie, 14.6 million people). In both cases, the prevalence, which has increased gradually from 14.4% in 2006, increases with older age and lower education level.

Based on the information from the Secretariat of Health for 2019-2021, the research group found that in the six locations included in their study, peripheral vascular complications and lower limb amputations were treated exclusively at the secondary level of care. Similarly, no follow-up reports for these cases were detected in the databases at either the primary or tertiary level of care.

At the national level, María Guadalupe Ramírez Rojas, a researcher at the CIESAS Southeast in San Cristóbal de las Casas, Mexico, and coauthor of the study, found that during the period mentioned above, approximately 47,000 cases of peripheral vascular complications were reported to health authorities, of which 5.46% occurred in Indigenous populations. In the state of Oaxaca, 2000 hospital admissions were reported, of which 16% were patients of Indigenous origin.

When discussing the type of medical services offered to patients with these types of complications in Oaxaca, Ramírez Rojas noted that over 90% of admissions occurred in the emergency rooms. She also found that in this entity there were only four cases (all non-Indigenous patients) that received care at the tertiary level. For that same period, from 2019 to 2021, the number of cases registered in tertiary care services for the Indigenous population was zero.

Ethnicity Data Lacking

“Although the principle of equality is fundamental to the health system, avoiding the disaggregation of data by ethnicity may obscure the specific needs of Indigenous communities, such as the management of diabetic foot,” said Ramírez Rojas. This situation “limits the ability to design prevention and treatment strategies tailored to the conditions that these patients face.”

In addition, the lack of adequate data collection not only affects health services planning but also perpetuates the historical marginalization of Indigenous communities and other groups, said Ramírez Rojas. “Not having disaggregated information limits our understanding of the social and economic determinants that influence health, which is crucial to formulating more equitable and fairer health policies.”

Jesús Elizarrarás-Rivas, a coauthor of the study, said that even though the locations studied in the Tlacolula valley are relatively well connected to urban centers, Indigenous populations have limited access to specialty healthcare. They almost always come to the clinic when they’re already facing severe complications from their disease. Elizarrarás-Rivas is a pediatrician, geneticist, and head of the Health Research Coordination of the Mexican Social Security Institute (IMSS) in Oaxaca.

These adverse factors, along with changes in eating habits, are common in many vulnerable populations across the country, he said. Other Indigenous groups in Mexico may face similar or “even worse” issues.

“These factors, combined with poverty and lack of adequate infrastructure, create an environment conducive to the development of serious complications such as diabetic foot and others related to metabolic syndrome and dyslipidemia,” said Elizarrarás-Rivas.

Cultural barriers such as distrust in the health system resulting from previous poor experiences, lack of adequate information about self-care of chronic diseases, as well as a paucity of interpreters or health personnel speaking Indigenous languages further complicate the situation.

IMSS-Bienestar recently was assigned to coordinate and improve care in many rural state clinics that previously operated with few resources or without the constant presence of physicians. Under its leadership, infrastructure improvement should continue to ensure that clinics in remote areas have the supplies and staff needed to serve Indigenous communities promptly, said Elizarrarás-Rivas.

IMSS-Bienestar health services may also play a key role in collecting data specific to the communities it serves, thus enabling a more efficient design of health policies that address the needs of Indigenous populations, helping to prevent chronic complications such as diabetic foot.

Finally, Elizarrarás-Rivas proposed that in the new operating scheme in rural clinics, healthcare professionals emphasize prevention and self-care of chronic diseases, thereby promoting the early detection of complications.

“It would be advisable to link medical services to communities in such a way that health personnel can provide home follow-up to patients with previous ulcers to avoid complications. It will also be important to promote social participation in health and coordination with local authorities, schools, and other community bodies to work on prevention,” he concluded.

Montesi Altamirano, Ramírez Rojas, and Elizarrarás-Rivas, reported having no relevant financial relationships.

This story was translated from theMedscape Spanish edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.