Our report on diabetes-related amputation in Barbados (1), together with data from Morbach et al. (2), offers tentative evidence of a different hierarchy of mortality following lower-extremity amputation in people with diabetes in the developing world, with more deaths caused by overwhelming infection. In a recent Caribbean publication, septicemia was again the most common cause of postoperative mortality (3), contributing to 47% of the recorded deaths. In the Barbados study, many of the deaths following major amputations occurred rapidly; one-quarter of below-the-knee and almost one-half of above-the-knee amputees died within 2 months of surgery. Anecdotally, local health care providers see this as a result of late presentation. Indeed, despite three-quarters of participants reporting that they examined their feet daily, 62% waited 1 week or longer and 31% waited over 2 weeks before seeking medical attention for a foot injury that eventually led to amputation.

If the delay in seeking health care is a key determinant, then much can be done. Education for patients and health care providers on diabetes management must be coupled with increased access to “multidisciplinary care” in the primary health care setting, including dedicated foot care clinics. This is possible. A World Health Organization review of diabetes in the developing world highlighted foot care interventions as feasible and cost-saving (4). Foot care is “low tech” with manageable costs in contrast to the significant economic consequences of ulceration and amputation. If interventions target people considered at high risk of ulcers (such as those with previous ulceration), these cost savings and health care benefits could be even greater.

No potential conflicts of interest relevant to this article were reported.

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