The insulin pen had been sitting on his kitchen table for months. The 46‑year‑old man, a retired Sri Lanka born chef living in the Toronto area, had survived oral cancer, pancreatitis and a lifetime of hard work. But nothing frightened him more than the small plastic pen meant to save his life. On a June morning, during a routine check after his jaw surgery, he finally confessed his fears.
“I haven’t used insulin in almost two years. I refill it. I carry it. But I don’t inject it. I don’t want to go blind. My uncle took insulin. After that … everything went bad.”
His fear is not unusual. Across Canada, clinicians are seeing a troubling pattern: Patients, even those with dangerously uncontrolled diabetes, quietly avoiding insulin. They nod politely in appointments, refill prescriptions and promise to “try harder,” but behind closed doors, they hide needles in cupboards, skip doses and pray their blood sugars will behave.
For the Sri Lankan chef, the consequences were written across years of lab results. His HbA1c (the key measure of long‑term diabetes control) had climbed to 10.6 from 7.3. He had tried multiple oral medications and even turned to insulin briefly in 2022. But after two months, he stopped. He never told his doctor. He simply carried the pen like a talisman, refilling it to avoid questions while quietly living with blood sugars far above the normal range.
He wasn’t careless. He wasn’t stubborn. He was terrified. A pattern is not that uncommon among the South Asian diaspora.
People from South Asia – the Indian subcontinent – develop diabetes earlier and at lower body weights than Western Europeans. One landmark Canadian study found that South Asians reach the same diabetes risk as a 40‑year‑old Western European man by age 25.
The reasons lie in a web of genetic and historical factors that increase insulin resistance and a four times increased risk of developing diabetes in South Asians, even when their blood sugars are normal, compared to the general population. Historical famine cycles created a “starvation adaptation,” priming South Asian bodies to store fat efficiently. Once a survival advantage, it now drives abdominal obesity and early metabolic disease in environments filled with processed foods and sedentary work. The biology is stacked against them. But biology is not the only barrier.
Insulin, for many patients, is not just a medication; it is a marker of defeat.
Patients describe insulin as:
- Proof they “didn’t take care of themselves”
- A last resort
- A dangerous drug that causes blindness or kidney failure
- A sign of severe illness that affects marriage prospects
- Something that “weakens the body”
- A punishment for not controlling diabetes .
These beliefs are reinforced by family stories, community narratives and misinformation passed quietly between relatives.
In one study of Pakistani patients, 73 per cent believed insulin was a last resort. A quarter said they would never use it under any circumstance. Even after starting insulin, more than half were hesitant. However, nearly 80 per cent later reported improved glucose control and said they would recommend insulin to others. Fear, not science, shapes decisions.
Health decisions in South Asian families are often communal. Patients consult spouses, siblings, elders and family members before accepting insulin or other therapies. Some insist herbal remedies are safer. Others view illness as fate or divine punishment. Religious practices such as fasting make insulin timing feel risky or impractical. Concerns about the origins of insulin including fears that it may contain animal derivatives add another layer of hesitation. Social stigma is equally strong. Patients report hiding insulin from coworkers, avoiding injections in public and skipping doses during social events. For some, insulin becomes less of a therapy and more a visible badge of disease.
During my clinical encounters, patients often tell me insulin will make them “too weak to work,” or that starting it will make others think they’re “really sick.” These conversations show how social, economic and religious pressures shape insulin decisions long before the prescription is written.
The fear is especially visible in professions dominated by South Asian immigrants, like trucking. Nearly one in five truck drivers in Canada is South Asian, and in cities like Toronto and Vancouver, they make up more than half of the industry.
For decades, truck drivers who used insulin were automatically barred from cross‑border work under U.S. federal rules. The ban was lifted in 2018, but many drivers still believe insulin will cost them their livelihood, a fear reinforced by years of misinformation and complicated medical requirements. Long-haul schedules, unpredictable meals and limited rest stops make injections feel unsafe or impractical. Some drivers skip doses to avoid injecting in public or while alone on the road.
The result is predictable: worsening diabetes and long-term complications.
Language barriers deepen the crisis. Many South Asian patients struggle to understand written instructions or medical terminology. Even with interpreters, cultural nuances distort meaning. Patients nod politely during appointments without fully understanding how to inject insulin or adjust doses. Some fear hypoglycemia but don’t know how to recognize it. Health literacy gaps turn a simple injection into a mysterious, frightening act.
A colleague told me about a patient who agreed to use insulin at every visit but never did. The patient later admitted he didn’t know how to inject it and was too embarrassed to ask.
When the retired chef was hospitalized for cancer surgery, endocrinology was consulted. His sugars were dangerously high. Though his body was exhausted, his fear was greater than his illness.
But this time, something shifted.
The team (doctors, nurse educators) sat with him and asked gently what scared him most. He didn’t talk about needles. He talked about his uncle. He talked about blindness. He feared disappointing his family. He feared being seen injecting at work. He feared being judged.
He feared failure.
The team involved his family, explained insulin in simple language, addressed religious concerns and showed him how to inject safely. Most importantly, he was being listened to without judgment. The team normalized insulin as part of diabetes progression, not a punishment.
Slowly, his fear softened. He agreed to try again. Weeks later, his sugars began to fall. He felt less tired and more in control. He felt proud.
His story is not unique. It is a quiet crisis, thousands of patients quietly avoid insulin, not because they don’t care, but because they are afraid. They fear stigma, judgment, losing independence, disappointing their families or being seen as “sick.”
But fear can be softened when met with compassion, cultural understanding and clear communication.
The path forward requires:
- Culturally competent care
- Family‑inclusive counselling
- Community‑based education
- Support for truck drivers and shift workers
- Religious‑sensitive care plans
- Clear, simple educational materials
- Early conversations about insulin
- Addressing stigma directly
Diabetes is not just numbers on a chart. It is culture, family, identity and history. It is fear carried silently. For one man, insulin was the thing he feared most. Now, it is the thing that keeps him alive. And that is the story that needs to be told. Told loudly and urgently, not just in clinics, but in families, social and religious gatherings and living rooms across Canada. Because insulin doesn’t just lower blood sugar. It restores futures.
This article was written as part of the SPARC teaching newsroom elective in partnership with Healthy Debate.
