Shawna, a pregnant Pima Indian, calls diabetes a scourge. "Diabetes is a sign that this life we’re living isn’t our life," she says. "The one our ancestors had was way better."
Before World War II, diabetes was rare among Pima Indians. Today, however, Shawna is among the 12,000 tribal members on the Gila River Reservation in south central Arizona who have the highest recorded rate of diabetes of any population in the world.
The decline of agriculture set the stage for the health crisis, says Carolyn Smith-Morris, assistant professor of anthropology and author of the new book Diabetes Among the Pima: Stories of Survival (University of Arizona Press, 2006), the first ethnographic account of diabetes in a community. The dramatic change of diet and reduction in activity levels, as well as a genetic predisposition to the disease, led to the epidemic, which affects 50 percent of the adults on the reservation, she says.
For more than 30 years, the National Institutes of Health and other government and private agencies have studied the disease in the isolated Pima population. Much of what doctors know about diabetes, a chronic disease that develops when the pancreas stops producing insulin, is based on research with the Pimas.
But care practices that work for other cultures have not been as successful with the Pimas. As a medical anthropologist, Smith-Morris has helped health care workers at Gila River better understand the Pima culture and its attitudes about diabetes. Her research underscores the need to understand cultural habits when applying scientific methods.
Beginning in 1996, Smith-Morris lived and worked part time on the Gila River Reservation, attending health care classes, visiting medical clinics and joining holiday parades, birthday parties and bingo nights. "After two and half years, I was finally invited to my first family memorial, spent my first nights in Pima homes, and began in earnest to study life at Gila River," she says.
From information gathered through personal interviews, surveys and observation, Smith-Morris’ research suggests that the Pimas’ diabetes epidemic can be curbed through a community-based approach tailored to their culture.
In the past, most health care was delivered at one hospital that serves the 372,000-acre reservation, where most residents live in poverty and many do not own cars. Buses run regularly to transport patients to medical appointments, but the Pima culture does not live by the clock, she says. In fact, while living among the Pima, Smith-Morris deliberately slowed the pace of her big city gait to match their more leisurely pace.
Based in part on her research, the tribe has spent millions of dollars to develop community-based clinics staffed by field nurses and case managers who provide more home-based care.
Smith-Morris’ research also suggests that improving prenatal care for Pima women like Shawna can help curb the epidemic. Nearly 12 percent of pregnant women on the Gila River Reservation are diagnosed with gestational diabetes, compared with the U.S. average of 4 percent. Women with gestational diabetes and their babies are more likely to develop Type 2 diabetes and its complications of kidney failure, blindness and amputations later in life.
"The Pima want to avoid diabetes," Smith-Morris says. "They want to learn, but not always through the traditional Western methods of written materials and lectures. This epidemic is about a culture defining its path in an industrial world."
Smith-Morris’ current research focuses on diabetes prevention in the urban setting of South Dallas, where 33 percent of families live in poverty and 61 percent are unemployed. She developed the diabetes prevention component of a proposed $15 million project to create a wellness center in a South Dallas neighborhood. The Baylor Office of Health Equity and the Foundation for Community Empowerment are developing plans for the community-based program.
"My advocacy in these projects has impressed upon investors and planners that healthier lives need less clinic-based, biomedical intervention and more infrastructure support such as family-friendly neighborhoods and jobs that pay a living wage," she says.
For more information: smu.edu/smith-morris
– Nancy Lowell George (’79)