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A political economy of diabetes, pregnancy, and identity in the Gila River Indian Community Item Type text; Dissertation-Reproduction (electronic) Authors Smith-Morris Carolyn, 1966- Publisher The University of Arizona. Rights Copyright © is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author. Download date 05/10/2021 14:51:02 Link to Item http://hdl.handle.net/10150/279885 INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. 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ProQuest Information and Learning 300 North Zeeb Road, Ann Arbor, Ml 48106-1346 USA 800-521-0600 A POLITICAL ECONOMY OF DIABETES, PREGNANCY, AND IDENTITY IN THE GILA RIVER INDIAN COMMUNITY by Carolyn M. Smith-Morris © Carolyn M. Smith-Morris 2001 A Dissertation Submitted to the Faculty of the DEPARTMENT OF ANTHROPOLOGY In Partial Fulfillment of the Requirements For the Degree of DOCTOR OF PHILOSOPHY In the Graduate College UNIVERSITY OF ARIZONA 200 1 UMI Number 3031404 Copyright 2001 by Smith-Moris, Carolyn Markee All rights reserved. A UMI UMI Microform 3031404 Copyright 2002 by Bell & Howell Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. Bell & Howell Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 n THE UNIVERSITY OF ARIZONA ® GRADUATE COLLEGE As members of the Final Examination Committee, we certify that we have read the dissertation prepared by Carolyn Markee Smith-Morris entitled A Political Economy of Diabetes. Pregnancy, and Ident-ft-v in the Gila River Indian Community and recommend that it be accepted as fulfilling the dissertation requirement for the Degree of Doctor of Philosophy f/c/ /o f Date Aw. VLi ilL. (V\ ft StfT ,2031 Susan U. Philips ' ' Date 9/it /o! Mark Nichter Date vw; A ie R. Joe U Date Date Final approval and acceptance of this dissertation is contingent upon the candidate's submission of the final copy of the dissertation to the Graduate College. I hereby certify that I have read this dissertation prepared under my direction and recommend that it be accepted as fulfilling the dissertation requirement. ffe-f/or Dissertation Director Ana T. nrrfr Date 3 STATEMENT BY AUTHOR This dissertation has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library. Brief quotations from this dissertation are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the copyright holder. SIGNED: (jOi a* Lw ill- Hfr-A N Carolyn Mc Smith-Morris 4 ACKNOWLEDGEMENTS My first thanks go to the people of the Gila River Indian Community, its Tribal Council and Health Care Corporation, and those involved in the project who have become close friends. I am grateful and humbled by the financial support of this project by several institutions. The pilot study for this dissertation received fUnding from Hu Hu Kam Memorial Hospital of the Gila River Health Care Corporation as well as an Edward H. Spicer Scholarship from the Department of Anthropology, University of Arizona. Funding for the dissertation research came from: a grant from the Wenner-Gren Foundation for Anthropological Research; a dissertation improvement grant from the National Science Foundation; and a dissertation award from the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services. My proposals and awards were handled with professionalism and courtesy, and I will remain grateful for them throughout my professional career. The members of my dissertation and preliminary exam committees have provided me with incredible support, encouragement, and edifying challenges. I wish to thank especially Ana T. Ortiz, Mark Nichter, Susan U. Philips, Jennie R. Joe, and Tom Weaver. Others who had a formative impact on me and to whom I am grateful for a rewarding and successful graduate career include: Trudy Griffin-Pierce, Stephen L. Zegura, Nancy J. Parezo, Diane Austin, M.E. Morbeck, Carol Kramer, and Leonard Ditmanson. I lastly thank my kin, nuclear and extended, for encouraging me and helping to make my doctorate degree a possibility. 5 TABLE OF CONTENTS LIST OF TABLES 8 ABSTRACT 9 CHAPTER I: BACKGROUND AND POLITICAL ECONOMY OF PIMA DIABETES. 10 I. Political Economy as a Theoretical Framework 13 II. The Pima in Historical Context 14 International Context 19 III. Pimas' Articulation with Capitalism 22 Mixed Modes of Production Among the Pima 28 A Ruinous Commodity for the Pima: Food 32 IV. Applying Political Economy to Diabetic Health Programming 37 Review of the Problem 37 Community Profile 41 Other Research at Gila River 46 Diabetes Research 49 Political Economy and Diabetic Health 52 V. Conclusion 57 CHAPTER 2: HEALTH RESEARCH WITH NATIVE AMERICANS (METHODS) 62 I. U.S. Policy Toward Native Americans - Reasons for Indian Skepticism 63 From Indian Health Service to Tribal Self-Determination 70 II. Entering the Community, Designing the Research 74 Gaining Permission 77 Accounts and Interviews 78 UI. "The Diabetes & Pregnancy Project" - Overview 81 IV. Health Research Among the Pima - The Changing Role of the Anthropologist 89 CHAPTER 3: FIGHTING THE EPIDEMIC THROUGH PREGNANT WOMEN'S BODIES 92 I. An Ethnography of Pregnancy 93 Summary Information: Pilot Study 98 Summary Information: Ethnographic Project 103 n. Pima Women's Experiences of Prenatal Care and Diabetes 109 Issue #1: The Confusion of Diabetes Screenings 109 An Illustrative Case 113 Issue #2: Understanding Risk 119 6 TABLE OF CONTENTS - Continued Issue #3: Co-Morbid and Complicating Factors 122 III. Conclusion 125 CHAPTER 4: COMPETING KNOWLEDGES AND RELATIONSHIPS WITH BIOMEDICAL PROVIDERS 131 I. Biomedicine's Rise to Hegemonic Dominance 132 II. Biomedicine and its History at Gila River 137 III. Women's Reaction to Biomedical Care on the Reservation 140 1. Complaints About Doctors 143 2. Reasons for Skipping or Avoiding Care 149 3. Not Following Advice/Taking Medication 152 IV. Provider Perspectives 154 V. Communication and Power 157 Women Asking Questions of Providers 158 Learning the Rules of Communication 160 Household Communication 162 Trust 166 'Stubbornness' and Counter-Hegemonic Communication 170 Ambiguity and Obtrusiveness 172 VI. Conclusion 174 CHAPTER 5: PIMA IDENTITY IN THE DIABETES EPIDEMIC 177 I. Community Identity 178 Countering the Diseased Identity 180 II. The Rejection of Biomedicine 183 Collective Identity, Loner Disease, and the Vulnerable Social Self 184 III. Tradition, Elders, and the 'Proper' Pima Approach to Diabetes 188 IV. Adapting the Diabetes Messages 191 Further Recommendations 196 V. Conclusion: 202 APPENDIX A: HUMAN SUBJECTS APPROVAL 206 APPENDIX B: RESEARCH QUESTIONS - INDIVIDUAL INTERVIEWS 208 APPENDIX C: RESEARCH QUESTIONS - FOCUS GROUPS 212 APPENDIX D: RECOMMENDATIONS 213 APPENDIX E: MAPS OF THE GILA RIVER INDIAN COMMUNHTY 214 7 TABLE OF CONTENTS -Continued REFERENCES 215 8 LIST OF TABLES Table 1, Sample of 24-Hour Recall Food Inventories 35 Table 2, Market Prices Comparison 44 Table 3, Focus Group Discussion Materials 86 Table 4, Pilot Study Chart Reviews 99 Table 5, Pilot Study/Age and Gestation 101 Table 6, Pilot Study/Other Information 103 Table 7, Summary of Ethnographic Interviews 104 Table 8, Districts Represented in Ethnographic Interviews 105 Table 9, Location of Interviews 106 Table 10, Response Summary to Select Questions 107 Table 11, Blood Sugar Thresholds for Diagnosis of GDM 112 9 ABSTRACT More than half of all Pima Indians over age 35 have Diabetes Mellitus and prevalence rates continue to rise; this despite billions of dollars spent every year on research and prevention activity by the National Institute of Health, the American Diabetes Association, and the Indian Health Service nationwide. Because of the many health problems which can occur in conjunction with uncontrolled diabetes, including heart disease, kidney disease, neuropathy, retinopathy,