ASK Clerence Natnaur what makes her happy and the young woman with bandages on her feet answers softly, “I love listening to music, playing guitar and singing.”
Later she will sing a hymn for her visitors, at her home in Vanuatu, tapping time with feet that are missing their toes.
What’s more, diabetes is also making Clerence, 22, blind.
During the past 20 years there has been an explosion of this disease, particularly in the Pacific Islands where the incidence is among the highest in the world.
Clerence gets around her earth-floor family home in Erakor Village near Port Vila with the help of a walking stick.
To venture further there is the wheelchair her father used after his legs were amputated because of diabetes complications. He died last year, aged 48, from kidney failure.
Amputations are complications that are in plain sight. Eye damage is the hidden curse of diabetes.
Clerence has dense cataracts and diabetic retinopathy, whereby the disease causes bleeding at the back of eye (the retina).
High blood sugar can lead to cataracts, glaucoma, and diabetic retinopathy which is the most common cause of vision loss for diabetics and is a leading cause of blindness among working-age adults.
Removing Clerence’s cataracts should improve her eyesight but it must also be done so the back of her eye can be seen to assess her retinopathy. Then laser surgery can be done to stop the bleeding and preserve her sight.
The trouble is, cataract operations have twice been cancelled because of skin infections near Clerence’s eyes. If infection got into her eyes it could cause total blindness.
The operations are done by doctors visiting with twice-yearly diabetic outreach teams which are part of the Fred Hollows Foundation’s diabetic eye program.
It is a long time to wait but Clerence hoped she would be third-time lucky when the outreach team returned in October.
Her story is about missed opportunity, misunderstanding, superstition and a health system struggling to cope.
She knew her eyesight was poor a decade ago at school when she couldn’t see the blackboard. Much later, Clerence learned diabetes was diagnosed back then but nothing was done.
“My father was upset and he couldn’t accept that I would need lifelong treatment with insulin,” she said.
Clerence learned she had diabetes when infection landed her in hospital years later.
In 2014, the toes on her right foot were amputated after infection spread from a cut on her big toe.
Last year, poor eyesight led to the loss of the toes on her other foot. She stood on an insulin needle causing a small puncture wound on her little toe.
Her family first tried traditional treatments. Clerence even stopped taking insulin on the advice of a local healer.
Often when doctors see patients for the first time damage is advanced, Vila Central Hospital general surgeon Samuel Kemuel said.
“Most start with just a tiny injury and present late to the hospital, sometimes because they seek an alternative source of medicine, traditional medicine and wait until that doesn’t work. So by the time we see them it can be extreme.”
About half the general surgeries at the hospital relate to diabetes. Two-thirds of patients seen by the outreach eye team are diabetic.
Clerence tells the Herald she now knows better how to live with diabetes.
“Take your insulin, do more exercise, move and sweat. Eat the right food and eat enough, not a lot.”
That means less white rice, tinned fish, juices and soft drinks and more vegetables.
But that diet is expensive and sometimes she has to eat what the family eats.
No one in the family is in paid employment since her mother stopped work to nurse her husband a few years ago.
Her mother, Jeaneth, is in Samoa on a tourism course she hopes will lead to a job and an improved quality of life for the family. “That is her grand plan,” Clerence says.
The day before Clerence’s cataract operation is due there is bad news. Outreach team opthamologist Johnson Kasso has found cellulitis, a common bacterial skin infection, on her face.
Dr Kasso explains that makes the operation too risky. He will prescribe antibiotics and see her after a modern eye clinic funded by the Fred Hollows Foundation opens at the hospital in February.
Clerence is close to tears. She says later, “I really wanted it this year but it is not possible.”
But the new clinic improves her prospects. It will be headed by Kasso, a native of Vanuatu, who will become his country’s first resident opthamologist.
“Hopefully we will save enough of her vision for her to move around the house and have a reasonably normal life,” said Kasso.
The Fred Hollows Foundation NZ hopes to raise $70,000 for a new camera to examine patients’ eyes in Vanuatu. The camera will greatly improve the early detection of diabetic retinopathy and many other eye diseases, helping reduce the incidence of avoidable blindness.