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Sapiens: Can Medical Anthropology Solve the Diabetes Dilemma?

As the number of sufferers continues to rise, some researchers are moving in new directions to figure out how culture and lifestyle shape disease outcomes.

Sapiens reporter Kate Ruder covered the research of SMU anthropologist Carolyn Smith-Morris, who has studied diabetes among Arizona’s Pima Indians for more than 15 years.

Smith-Morris wrote about what she learned from her research in her 2006 book, “Diabetes Among the Pima: Stories of Survival.”

The Pima have the highest prevalence of diabetes ever recorded, although the disease is alarmingly on the increase throughout the United States. In an effort to understand the rise of the disease, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) from 1965 to 2007 focused on the Pima to carry out the largest continuous study of diabetes in Native Americans. Researchers examined the environmental and genetic triggers of the disorder, management of the disease, and the treatment of thousands of Pimas.

Smith-Morris is a medical anthropologist and associate professor in the SMU Anthropology Department in Dedman College. Her research addresses chronic disease, particularly diabetes, through ethnographic and mixed methodologies. She has conducted ethnographic research among the Gila River (Akimel O’odham) Indian Community of Southern Arizona, Mexicans and Mexican immigrants to the U.S. and veterans with spinal cord injuries.

The Sapiens article, “Can Medical Anthropology Solve the Diabetes Dilemma?” published Aug. 22, 2017.

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By Kate Ruder

Mary (a pseudonym) was 18 years old and halfway through her second pregnancy when anthropologist Carolyn Smith-Morris met her 10 years ago. Mary, a Pima Indian, was living with her boyfriend, brother, parents, and 9-month-old baby in southern Arizona. She had been diagnosed with gestational diabetes during both of her pregnancies, but she didn’t consider herself diabetic because her diabetes had gone away after her first birth. Perhaps her diagnosis was even a mistake, she felt. Mary often missed her prenatal appointments, because she didn’t have a ride to the hospital from her remote home on the reservation. She considered diabetes testing a “personal thing,” so she didn’t discuss it with her family.

As Smith-Morris’ research revealed, Mary’s story was not unique among Pima women. Many had diabetes, but they didn’t understand the risks. These women’s narratives have helped to explain, in part, why diabetes has been so prevalent in this corner of the world. An astonishing half of all adult Pimas have diabetes.

Medical anthropologists like Smith-Morris are helping the biomedical community untangle the social roots of diabetes and understand how and why the disease is exploding in the United States. Smith-Morris, based out of Southern Methodist University in Dallas, Texas, has been working on this cause for over 15 years—from a decade spent among the Pimas, to a new study sponsored by Google aiming to prevent diabetes-related blindness. Anthropology, she says, provides the most holistic perspective of this complex problem: “Anthropology seems to me the only discipline that allows you to look both closely at disease … and from the bird’s eye perspective.”

More than 30 million people in the United States are estimated to have diabetes, and it’s on the rise. If trends continue, 1 out of every 3 American adults could have diabetes by 2050, according to the Centers for Disease Control and Prevention.

The condition involves insulin, a hormone that regulates the way the body uses food for energy. In type 1 diabetes, the body stops making insulin entirely; those affected need daily insulin injections to survive. In type 2 diabetes, which accounts for the vast majority of cases, change is more gradual.The body slowly makes less insulin and becomes less sensitive to it over the years. Gestational diabetes, which strikes during pregnancy, can give mothers a dangerous condition called preeclampsia, which is related to high blood pressure and can harm both mothers and babies. Women with gestational diabetes are more than seven times likelier to later develop type 2 diabetes than women who do not have the condition in pregnancy, and their children are at higher risk of obesity and diabetes. If left untreated, diabetes can cause heart disease, kidney failure, foot problems that can lead to amputation, and blindness.

The preventative measures for type 2 and gestational diabetes are seemingly straightforward: eat healthy foods, lose weight, and exercise. Treatment for both can include taking medications. Yet prevention, lifestyle, and treatment cannot entirely solve the problem; family history, ethnicity, and other factors play a critical role in a person’s susceptibility to type 2 and gestational diabetes. Both forms of diabetes continue to plague Americans, particularly certain groups, including Native Americans. “My interest in diabetes grew out of an interest in Indigenous groups,” says Smith-Morris. “I took on diabetes because it was important to them.”

From 1965 to 2007, the Pimas of Arizona were the focus of the largest continuous study of diabetes in Native Americans. Conducted by researchers from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), it examined the environmental and genetic triggers of the disorder, management of the disease, and the treatment of thousands of Pimas. It also documented that they had the highest prevalence of diabetes ever recorded. The pivotal work told researchers much of what they know about diabetes today, including that obesity is a significant risk factor, and that a mother’s diabetes during pregnancy can pass risk along to her children.

The political and economic contributors to the Pima people’s health problems have long been well-known: Their traditional farming practices collapsed during the late 1800s and early 1900s when non-Native settlers upstream diverted essential water resources, contributing to poverty, sedentariness, and a lack of fresh food. Yet Smith-Morris felt something integral was missing from this picture: the Pimas’ stories.

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Anthropologyworks: SMU’s James Kennell among Top 40 cultural anthropology dissertations

The blog Anthropologyworks has cited the research of SMU medical anthropologist James Kennell as one of the best 40 North American dissertations in cultural anthropology during 2011. Kennell’s “The Senses and Suffering: Medical Knowledge, Spirit Possession, and Vaccination Programs in Aja,” was written in fulfillment of his doctoral degree.

The blog is a project of the Culture in Global Affairs (CIGA) research and policy program of the Elliott School of International Affairs at the George Washington University in Washington, D.C. CIGA’s mission is to promote awareness of the relevance of anthropological knowledge to contemporary issues and to enhance discussion and debate within and beyond anthropology about contemporary issues.

Kennell teaches “Health as a Human Right” and “Peoples of Africa” in the SMU Department of Anthropology.

Read about the Top 40.


Anthroworks presents its favorite 2011 North American dissertations in cultural anthropology. In compiling this list, I searched the “Dissertations International” electronic database that is available through my university library. The database includes mainly U.S. dissertations with a light sprinkling from Canada. I used the same search terms as I did in previous years.

True confession: these are my picks, and they reflect my preferences for topics — health, inequality, migration, gender, and human rights. Somebody else’s picks would look quite different. But this is the anthroworks list!

The 40 dissertations are arranged in alphabetical order according to the last name of the dissertation author. Apologies to the authors for my reduction of their published abstracts to a maximum of nine lines.

I would like to convey my congratulations to all 2011 anthropology Ph.D. recipients. I hope they go on to a successful career in — or related to — anthropology.

The Senses and Suffering: Medical Knowledge, Spirit Possession, and Vaccination Programs in Aja, by James Kennell. Southern Methodist University. Advisors: Caroline Brettell, Carolyn Sargent, Carolyn Smith-Morris, Paul Stoller.

In an Aja community of southwest Benin, multiple domains of medical knowledge and practice compete for control of illness meaning and sensory experience. Global health initiatives (vaccination and education programs), national health care structures, and Aja medico-religious practice each incorporate and manipulate the knowledge and practice of the other in order to create legitimacy and shape therapeutic trajectories. Biomedical nosology and disease prevention efforts conflict with local understandings of individual and community health concerning diseases that affect the skin. Efforts at the “sensibilisation” of the community regarding vaccinations and other global health initiatives is met with local medico-religious knowledge emphasizing a sensual experience of illness and healing for the individual and the community.

Read about the Top 40.

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Culture, Society & Family Health & Medicine

Tribe, urban poor supply insight into diabetes

Shawna, who is pregnant, calls diabetes a scourge. She is a member of the Akimel O’odham tribe in Arizona. “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 the members of the Akimel O’odhams, also known as the Pima. 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 in SMU’s Dedman College and author of the new book “Diabetes Among the Pima: Stories of Survival” (University of Arizona Press, 2006), the first ethno-graphic 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, says Smith-Morris.

“This epidemic is about a culture defining its path in an industrial world,” 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 Akimel O’odham 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 Akimel O’odhams.

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.

As a medical anthropologist, she has helped health care workers at Gila River better understand the Akimel O’odham culture and its attitudes about diabetes. She has spent 10 years studying the causes and conditions of the epidemic. Smith-Morris found that diabetes care practices that work in other cultures have not been as successful with the Akimel O’odhams.

From information gathered through personal interviews, surveys and observation, Smith-Morris’ research suggests that the Akimel O’odham’s diabetes epidemic can be curbed through a community-based approach tailored to their culture.

More than 95 percent of the population is obese, a risk factor of diabetes, but promoting jogging hasn’t worked well in a desert with few paved roads, Smith-Morris says. And a health care system based at one hospital is not always effective on a 372,000-acre reservation, where most residents live in poverty and where many residents don’t have cars. Buses run regularly to carry people to medical appointments, but the Akimel O’odham culture does not live by the clock, she says. In fact, while living among the Akimel O’odham, Smith-Morris deliberately slowed her big-city gait to match their more leisurely pace. In addition, diet change is expensive for a population where most live in poverty.

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 Akimel O’odham women like Shawna can help curb the diabetes 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.

She sees positive signs of change as tribal officials are taking more control of their health care system and health education. The hospital has hired more field nurses who travel to patients’ homes. Pima women are encouraged to fry their traditional bread in oil instead of lard.

Non-Native American health care workers also have a new opportunity to better understand their patients’ culture. Bill Knowler, head of the NIH diabetes, digestive and kidney disorders research office in Phoenix now requires all Gila River Reservation NIH workers to read Smith-Morris’ new book. &#8212 Nancy Lowell George

Related links:
Carolyn Smith-Morris
Gila River Indian Community
“Diabetes Among the Pima: Stories of Survival”
SMU Department of Anthropology
Foundation for Community Empowerment
Baylor Office of Health Equity
Dedman College of Humanities and Sciences