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Lessons from the Three Domains Influencing Pima Diabetes Carolyn M

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Lessons from the Three Domains Influencing Pima Diabetes Carolyn M Human Organization. Vol. 63. No. 1,2004 Reducing Diabetes in Indian Country: Lessons from the Three Domains Influencing Pima Diabetes Carolyn M. Smith-Morris The prevalence of diabetes among Pima (Akimel O'odham) Indians involves three important domains: political-economic, -eenetic. and cultural. Proerams in diabetes education have made noteworthv, imnrovements . in the last two decades in addressing- cultural information and attitudes. It is less common to see political-economic factors addressed, particularly the structural barriers to care that include poverty and unemployment. The genetic contributions to modem rates of diabetes have, perhaps, been overemphasized in the past, contributing to a sense that this disease is inevitable in American Indian populations. I review six lessons drawn from these domains and from diabetes prevention and treatment programs in Indian country: 1) the basic importance of cultural sensitivity; 2) the strengths of community participation; 3) the influential but not dominant significance of genetics; 4) some relevant structural changes in forms of health care; 5) fee need for political-economic change within tribes to sustain communitywide change; and 6) the significance of a stable financial foundation for diabetes programs. Key words: diabetes, political economy, community participation, Pima Indians imaIndians are better known aroundthe world for their 1990; Scheder 1988). Diabetes-related conditions account for diabetes than for their culture and history. More than 19.5 percent of all (age-adjusted) Pima deaths-four times Phalf of all Pima Indians over age 35 have diabetes, a that ofwhites and two times that of blacks in the United States condition arising from a body's decreased ability to metabo- (Newman et al. 1993). lize glucose (Knowler et al. 1990). Adult onset, noninsulin- Three domains of influence contribute to Pima diabetes: dependent diabetes, now called type 2 diabetes, is the most political-economic, genetic, and cultural. Stemming in pat common form of diabetes among Pima Indians. Data from from attention paid to diabetes by anthropologists, but also research conducted by the National Institutes of Health since from increasing involvement of native people in program 1965 reveal the incidence of Pima diabetes to have increased development, diabetes programs are improving their cultural for three successive decades in both men and women (Ben- relevance. Genetic contributions to modem rates of diabetes nett, Burch, and Miller 1971; Narayan 1997:173). Among have been overemphasized in the past, contributing to a sense the Pima, it is a leading cause of extremity amputation and that this disease is inevitable inNative American populations acquired renal disease, is associated with an increased risk (e.g., Kozak 1997). It is rarer to see political-economic fac- for ischemic heat disease and infections (Narayan 1997: 178), tors addressed, although it is possible for programs to deal contributes to higher risk for depression, and is, in turn, made with structural issues even if they cannot resolve them. In worse by depression and alcoholism (Hamood 1981; Lang this discussion, I review how each of these three domains influences diabetes rates at Gila River, then apply this knowl- edge in calling for holistic planning and programs that might best be able to reduce rates of this disease. First, I provide Carolyn M. Smith-Morris is an assistant professor of anthropology a brief profile of the Gila River Indian Community, where I at Southern Methodist University. The research for this article was conducted an ethnographic study on diabetes between 1997 supported by cm Edward EL Spicer Scholarship for Research in the and 2001. Foci of that study included the political-economic Southwest and Northern Mexico (University of Arizona), cm Arizona and historic factors in Pima diabetes, with an ethnographic ArchaeologicalandHistoricalSociety Scholarship (ArizonaStateMu- seum), anda Wenner-GmnFoundationdissertationrant. Theauthor is focus on the health and health care experiences of pregnant women and mothers. Methods for that research included: an outcome study of women enrolled in the Diabetes Education Center's prenatal classes; lengthy interviews with 90 com- munity members including 27 pregnant women who spoke both detailed andcomprehensive evaluations of the manuscript and suggestionsforfurther work. with me several times over the course of their pregnancy; HUMAN ORGANIZATION Figure 1. Gila River Indian Reservation and Surrounding Area Note: Numbers indicate reservation districts. Grande behavioral (and diet) observations of Pima women; extensive whom are Pima. The tribal economy is also supported by participation observation, including attendance with women two casinos. Nevertheless, the 2000 U.S. Census reported an of prenatal appointments; and a written survey of health unemployment rate of 24 percent, a median family income providers on the reservation. of $18,769, and 47 percent of families below the poverty level. Community Profile The reservation town of Sacaton is home to the Hu Hu Kam Memorial Hospital, the Diabetes Education Center, There are approximately 14,000 Gila River Indians, with and most government buildings. Public health nursing, 11,257 living on the reservation at time of the 2000 census. environmental health services, and other Indian Health Ser- The tribe's principal industries are agriculture, industrial vice (IHS) programs are active on the reservation. There is a parks, and recreational parks. Of the reservation's 372,000 small market with groceries, a few school supplies, minimal acres, 12,000 are being farmed by the tribe's Gila River household supplies, and a kitchen that serves breakfast and Farms and produce cotton, several grains, olives, and citrus, lunch in Sacaton, and another smaller market in Casa Blanca for a total value in 1999 of more than $25 million. Industrial (District 5). There is also a gas station with a food mart in parks employ close to 1,000 workers, almost one-quarter of Gila Crossing (District 6). Prices are relatively high in these VOL. 63, NO. 1, SPRING 2004 stores and fresh fruits and vegetables are available only at Indian Self-Determination and Education AssistanceAct, was the Sacaton market. There are also offices for tobacco tax passed in 1975 to, in effect, move many programs away from funding, Women, Infant and Children (WIC) services, Head the Bureau of Indian Affairs while maintaining U.S. legal and Start, and various tribal services in Sacaton, as well as the moral support for these services. This law allows tribes to Wellness Center gymnasium and weight room. take much of the responsibility and control for tribal health services away from the IHS, giving them more freedom to Historical Context for Pima Diabetes design and administer tribal programs. However, this makes tribal funds vulnerable to political attitudes and the chang- The Pima Indians have lived in southern Arizona for at ing federal priorities of each new administration (Joe 1991). least 500 years and may be descendants of the ancient Ho- Tribal health administrators continue to work with IHS area hokam who occupied southern and central Arizona for about offices and the Washington, D.C., headquarters for their bud- 1,100 years between about A.D. 400 andA.D. 1500 (Bahti gets, a relationship that has its strengths and weaknesses (see and Bahti 1997; Fagen, King, and Erick 1995). The eventual Noren, Kindig, and Sprenger 1998). The Gila River Indian loss of natural resources (e.g., water, land), the development Community participates in this contracting and has, in recent of dependency on the federal government for food, and the years, administered much of the tribal health programming eventual resurgence of Pima autonomy and self-sufficiency through its own Gila River Health Care Corporation. have mirrored the experience of many Native American groups. Political-Economic Factors The 19th century brought tremendous change to all Native Americans. The Indian Removal Act of 1830 threw The decline of farming set the stage for the diabetes epi- open the door for Anglo population expansion south and west demic in two ways. First, the change in subsistence activities across what would become U.S. territory. The Pima, like other from farming to wage labor increased sedentism. A cultural tribes, were threatened by removal to Florida and Oklahoma value of "exercise for exercise's sake" had never been nec- until the Gila River Indian Reservation was created in 1859 essay in the precontact Pima culture, given the demanding (Bahti and Bahti 1997). As populations in the West grew, tasks of daily life. Second, the need for alternative sources of access to water became increasingly contested. Before the food led-not inevitably but certainly-to subsequent reli- 1860s, Pimas had maintained their agricultural fields and ance on government commodities and other processed foods. irrigation canals based on knowledge from a long history of Commodities held a leading position in the introduction of agricultural subsistence. There is archaeological evidence of capitalist relations at Gila River, especially fatty and sweet Hohokam irrigation farming dating as far back as A.D. 800 foods and drinks. These processed foods, made available first (Castetter and Bell 1942:28). But growth fostered by the through government rations and later in the fast food market, building of railroads, in addition to eventually oversupply- have had a highly negative and steadily worsening impact ing the market with goods and flooding the Southwest with on Pima health. tourists and migrants, brought a heavy toll in the lives and Arise in dietary intake of fat from 15 percent in the 1890s liberty of Native Apiericans. to 40 percent in the 1990s is considered another necessary but By the end of the 19th century, almost all of the Pima not sufficient condition for the high rate of diabetes in this farms had dried up due to Anglo violations of the Pimas' community (NIDDKD 1996: 19). Indeed, approximately 95 "prior appropriation" rights to the Gila River water flow percent of Pima Indians with diabetes are overweight (ibid.: (see Kelsey M McAteer 1879 as described in Dobyns 1989).
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