A few weeks ago, we launched The ZIP Code Lottery — a data narrative showing how amputation rates in Los Angeles County track almost perfectly with poverty, not clinical severity. It struck a nerve. The response told us something important: people want to see the data, and they want it to be impossible to look away.
Then we zoomed out. The Amputation Heat Map took the same question national — mapping PAD-related amputation rates by state and congressional district using published Medicare data. Mississippi, Louisiana, Alabama, South Carolina, Texas. The Deep South corridor lit up like a flare. The “Find Your Representative” tool lets anyone type in a ZIP code and land directly on their congressperson’s page. Because this is a policy problem.
Now we’ve gone global.
Every 20 Seconds
Every 20 Seconds is an interactive world map of diabetes-related amputation burden — covering more than 130 countries with four switchable data layers: a composite limb threat index, diabetes prevalence, percentage of cases undiagnosed, and healthcare expenditure per person with diabetes.
The title is not hyperbole. It comes from our own JAMA review and the IDF: every 20 seconds, somewhere in the world, a lower limb is lost as a consequence of diabetes.
The data draws on the NCD Risk Factor Collaboration and WHO analysis published in The Lancet in November 2024 — the one that put the global diabetes count at 828 million adults, more than quadrupling since 1990. It also integrates the IDF Diabetes Atlas (11th edition), the Global Burden of Disease Study 2021, and published country-level amputation data from Moxey (Diabet Med 2011), Hughes (EJVES 2020), the OECD, and VASCUNET.
What the Map Shows
Three things jump out immediately.
First, diabetes prevalence alone does not predict amputation rates. Japan and South Korea have among the lowest amputation rates in the world despite significant diabetes burdens — because organized systems of specialist foot care, early detection, and revascularization infrastructure intervene before ulcers progress to limb loss. This is the clearest possible evidence that amputation is a systems failure, not a disease inevitability.
Second, the undiagnosed fraction is the hidden accelerant. Globally, 59% of adults with diabetes are untreated. In many countries across South Asia, sub-Saharan Africa, and the Middle East, more than half of all diabetes cases remain undiagnosed. These are also the populations most likely to present late, with advanced tissue loss, when the window for limb salvage has already closed.
Third, health system financing matters. The OECD data reveals that countries with publicly financed health systems show lower amputation rates than insurance-based systems — a difference of approximately 4.5 amputations per 100,000 — even after adjusting for diabetes prevalence. Pakistan, with the highest age-standardized diabetes prevalence on Earth (31.4%) and health spending of just $138 per person with diabetes, sits at the extreme end of the composite index.
The Zoom Stack
All three maps are now cross-linked. An “Explore the Series” navigation strip at the bottom of each site connects them:
- The ZIP Code Lottery — LA County, published evidence on amputation disparity at the neighborhood level
- The Amputation Heat Map — US national, by congressional district, using Medicare PAD data
- Every 20 Seconds — 130+ countries, synthesizing the IDF, GBD, Lancet, and published amputation literature
The idea is simple: the same story told at three scales. A funder looking at the global map can drill down to a US congressional district and then to a specific LA County ZIP code. A community health worker in Boyle Heights can zoom out and see that the pattern in their neighborhood is not an anomaly — it is a fractal of a worldwide crisis.
Why We Built This
We’ve spent years publishing the evidence. Stevens in Health Affairs (2014) showed the disparity. Fanaroff in JAHA (2021) sharpened it nationally. Kassavin in JAMA Surgery (2023) confirmed it at the county level. Our own JAMA review (2023) laid out the full clinical picture — 18.6 million people affected by diabetic foot ulcers each year worldwide, 80% of amputations preceded by an ulcer, five-year mortality after major amputation exceeding 70%. Our NEJM paper (2017) established that “healed” is not the right word — patients with closed wounds should be considered in remission, because recurrence rates rival cancer.
What the literature does not produce by itself is a way to hand all of that to someone who is not a vascular surgeon or an epidemiologist and have them immediately understand what is at stake. These maps are that attempt. They are designed to do their work in a single sitting — in front of a congressional staffer, a hospital CEO, or a foundation program officer.
The amputation crisis is not subtle, and it is not mysterious. It is a failure of access, systems, and political will — mapped in high resolution from ZIP code to planet.
Explore the maps. Share them with your representative. Share them with your funder. Share them with your team.
Because every 20 seconds, we’re losing another one.
Sources: NCD-RisC/WHO, Lancet 2024; IDF Diabetes Atlas 11th ed.; GBD 2021; Moxey et al., Diabet Med 2011; Hughes et al., EJVES 2020; Carinci et al., Acta Diabetol 2016; VASCUNET; Kassavin et al., JAMA Surgery 2023; Armstrong et al., JAMA 2023; Armstrong et al., NEJM 2017; Stevens et al., Health Affairs 2014; Fanaroff et al., JAHA 2021.
Leave a Reply