Our correspondent and weekly Q&A columnist Wil Dubois is a community diabetes educator in rural New Mexico. He works with Native populations, and spent a good deal of time over the last few years teaching with the national ECHO program (Education through Cultural and Historical Organizations).
She was a small lady with smooth mocha skin. Despite being a tribal elder, her hair was black silk without a whisper of grey. In the fashion of her people, she wore a long dark skirt and neon-red velvet blouse. She was adorned with over-sized sand-cast silver and turquoise jewelry and she wore a pleasant and impassive expression on her face.
As I handed her a glucose meter that I'd done a practice demo blood test on, her eyes went as hard as flint when she told me, “I can’t touch your blood. You are my enemy.”
That word stopped me in my tracks. I nearly dropped the glucometer. I don’t have any enemies, and it never occurred to me that I might be someone else’s. Especially not someone I had just met for the first time. “Diabetes is the enemy. Not me,” I said.
Unflinchingly she replied, “You are bilagáana.” That’s Navajo for white man. Given what we bilagáanas did to her people 150 years ago, I guess I couldn’t blame her, and at any rate, I’d long ago learned that you can’t change Native culture or traditions. They are cast in iron and encased in stone — as unchangeable as the laws of physics.
When it came to the tricky task of getting Native Americans to understand and take part in their diabetes management, that culture and tradition could be as cripplingly stubborn as a severe hypo for someone trying to walk up or down a hill.
Native Americans and Diabetes
I had first learned that as a child growing up among the Navajos, Utes, Apaches, and Pueblo Indians. And I had just spent the previous four years teaching for the University of New Mexico School of Medicine’s Project ECHO, where fully two-thirds of our trainees were Native Americans.
So I know Native customs. But despite all my experience, this was my first direct encounter with the Navajo aversion to blood. But Navajo blood was now my problem. Well, sugar in their blood, anyway.
The Navajo tribe is the largest in the Untied States, with over 300,000 members. Their reservation is larger than the state of West Virginia, and sprawls over parts of Arizona, New Mexico, and Utah. And the Navajo also have a diabetes problem that’s as big as their reservation.
Navajo diabetes prevalence is 22.9% for all adults over age 20. Looking just at Navajos over age 40, that rate rises to more than 40%. Comparing those figures to the official numbers for the U.S. at large — a 9.3% prevalence — you can get a sense of the scale of the problem the Navajos are facing. And it’s not just the Navajo. All Native American groups are up to their ceremonial feather headdresses in diabetes, with the Pimas in southern Arizona getting the dubious prize for the most diabetes, with prevalence rates approaching 80% for tribal members in late middle age.
So what are the Navajo, and other tribes, doing about diabetes? A lot. The Navajo have one of the best programs to combat diabetes in the United States, and they aren’t alone. And unlike diabetes care in non-native communities, money isn’t the biggest problem.
Natives have free healthcare through the Indian Health Service (IHS), plus many tribes pump large sums of money from oil and gas revenues, or casinos, into their in-house healthcare systems. When the Jicarilla Apache Nation didn’t care for the condition of the IHS hospital in their capital of Dulce, New Mexico, they just built a new one for the government.
For all the good it did them. They’ve also built their very own dialysis center. For a tribe of just 3,000 members.
And that’s the crux of the dilemma. The Native tribes have a bigger problem than the rest of us, but better resources. And yet they still seem to be losing the battle.
Diets to Blame?
Many people in Indian Country believe that the “traditional” Native diet is to blame for the stratospheric diabetes rates. For the Navajo this includes fry bread, a white flour paste boiled in melted lard to create a puffy flatbread product. How on earth did such a thing become a traditional food? One word: Commodities.
For decades after Word War II, the main supply of food on most “Indian Reservations” was government-supplied industrialized food chain products: Canned and boxed foods. Fry bread is actually a creative solution to a nutritional dilemma: Just WTF can you make to eat with lard and flour?
Still, at least three generations of Natives grew up eating this stuff, so it’s now embraced as the “traditional diet.” And the rise of Native diabetes follows the trajectory of commodities, so the main area of intervention in Native diabetes programs is in trying to change the way people cook. This varies from advocating modest diet changes to radical calls for a to return pre-European-contact raw diets. But it’s a tough, uphill battle. Native old folks, like old folks everywhere, don’t like to be told what to do; and the cultural demands for respect of elders ingrained in most Native tribal members makes intervention that much more difficult.
Progress is slow and the losses are mounting. Remember the Jicarilla Dialysis center?
Talking Tribes and Moving Forward
What about the White Man’s solution of the holy medicine cabinet? Natives, especially older ones, aren’t too keen on taking “White Man’s Medicine,” my Native students tell me, and often rely instead on traditional cures. I’ve planted the idea in the heads of many of my native students that diabetes is a White Man’s curse brought on by our white food and therefore requires a White Man’s medicine, but I’ve yet to hear back from any of them if this motivational approach worked.
Personally, I think the future looks bright for the tribes in their fight against the epidemic. If not for this generation, then for the next. When I taught with ECHO, one of the first things I asked was how many students had diabetes. Given our student’s demographics, it was always a great surprise to me how few PWDs (people with diabetes) we had in each cohort. Nearly none. But when I asked who had a family member with diabetes, all hands shot up. Whether or not they can move the elders, they can see the writing on the wall, and they want to eliminate diabetes as a tribal tradition.
My approach to teaching our Tribal students was to be respectful of their traditions but to try to create new definitions of who we all are. Diabetes is a tribe, too. And those of us who have it, as well as our loved ones, are members. That transcends language and culture and tradition. We can all learn from each other. I focused on teaching our students what diabetes was, and then I counted on their Native wisdom and traditions to figure out a way to use that knowledge to help their people.
Did that make a friend out of my new enemy? Did we sit down and smoke a peace pipe together? No. But at the graduation ceremony at the end of her four months of training she came up to me and rested one hand on my arm, as light as a feather, barely touching me, and said: “You are still my enemy… But you are a good enemy to have.”
“Thank you,” I told her, “I’m proud to be your enemy.” And for the first time, her eyes softened from flint and twinkled with mirth.