RESENHAS BOOK REVIEWS

James R. Welch

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. welch@ensp.fiocruz.br

DIABETES AMONG THE PIMA: STORIES OF SURVIVAL. Smith-Morris C. Tucson: University of Arizona Press; 2006 (Hardcover)/2008 (Paperback). 248 pp.
Hardcover ISBN: 0816525536
Paperback ISBN: 9780816525539

The Pima, an American Indian people from the southwest United States, are reported to have the highest prevalence of type 2 diabetes of any population in the world. In this ethnographic study, Smith-Morris proposes that, among the Pima, diabetes is more than just a biomedical phenomenon. Approaching the disease through the lens of pregnant women's experiences, including those overlooked by biomedical research and interventions, the author explores its sociocultural aspects as co-constructed by native individuals and health professionals. She proposes that the solution to diabetes among the Pima, which has deep biological, historical, and cultural roots, requires new community-based solutions that prioritize but do not exploit women's perspectives. The writing style is non-technical, drawing heavily on oral interviews and the author's own observations made in the course of extended participant-observation research.

The book is divided into five sections. The first opens with an analogy between the elusive problem of diabetes and ho'ok, a mythological witch whom the Pima say instilled such fear in mothers that they allowed her to quietly eat their children. It then characterizes the complexity of the diabetes problem, both medically and culturally, paying particular attention to gestational diabetes mellitus and recent intervention efforts targeting pregnant women. The second section reports on obstacles to diabetes treatment and discusses the various ways in which the contrasting interpretations of medical professionals and Pima individuals confound prevention strategies. The third part of the book details effective and counterproductive aspects of diabetes care among the Pima, emphasizing the qualities of patient-caregiver interaction, medical treatment goals, and parallels between medical controversies regarding diagnosis and ambiguities in Pima women's perspectives of the disease. The fourth section situates the Pima diabetes epidemic within the larger cultural and historical context, arguing that the disease is caused by complex genetic, historical, and cultural factors. After sharing a specific Pima socioeconomic history as it relates to diet and diabetes, the author argues that the Pima example is poignantly illustrative of broader American and global patterns. The fifth part explores how the Pima diabetes epidemic and the years of public attention afforded it contributed to a degree of collective surrender to the disease that must be overcome for prevention efforts to be successful.

Among the author's central arguments is the assertion that sociocultural aspects of the Pima diabetes epidemic are important from the diverse perspectives of anthropology, clinical medicine and public health. Furthermore, she identifies both the Pima people and biomedical professionals as participants in a single, historically derived sociocultural community and co-investigators of the disease. Just as health professionals grapple with diabetes simultaneously in medical terms and in the specific context of Pima society, Pima individuals deal with health and disease through their own experiences in conjunction with new biomedical readings of those experiences. Thus, such notions as health, risk, and diagnosis are defined and interpreted through ongoing multicultural discourse. According to the author, recognition of this dynamic is important because it results in layers of perception and misperception on the part of both medical practitioners and Pima individuals that have proved counterproductive to prevention efforts. For example, contrastive cultural understandings of risk serve to confuse what it means to be symptomatic and thereby prevent mutual intelligibility regarding the very notion of disease. The result is that some medical professionals blame the Pima for being diabetic while some Pima resort to avoidance or apathy as strategies for coping with diabetes. This occurs despite the mutual respect that tends to characterize caregiver-patient relations. These insights into the Pima diabetes epidemic serve to underscore the complexities of diabetes as a medical condition and as part of a specific sociocultural setting. They demonstrate that the disease involves both perception and biology.

The author's ethnographic strategy for addressing diabetes among the Pima privileges the experiences of pregnant women, a relatively narrow segment of the population. That focus appears to have been facilitated by the circumstances of her insertion in Pima society, which first occurred for the purpose of evaluating the health outcomes of a diabetes education program for pregnant women, and later involved conducting fieldwork during her own pregnancy. The author justifies paying exclusive ethnographic attention to pregnant women by representing them as the biomedical and sociocultural linchpins of the Pima diabetes epidemic. That assumption derives from recent research suggesting that gestational diabetes has the potential to provoke a self-maintaining cycle of acquired type 2 diabetes under certain circumstances. According to the author, the specific economic history of the Pima may have included a phase of severe famine followed by excess dietary fuels in subsequent generations, which are the necessary conditions for this cycle. Although the author presents this hypothesis of acquired diabetes epidemic as one among many explanations, it strongly informs many aspects of her ethnographic approach, including the decision to study diabetes among pregnant women and not other members of the Pima population. She argues that high diabetes prevalence among the Pima has many causes but is not inevitable. The pattern could be reversed by overcoming the sociocultural factors that lead to elevated in utero glucose levels.

Considering the author's goal of exploring social and cultural aspects of diabetes among the Pima through the limited lens of pregnant women, the book makes a compelling case for recognizing the complex connection between medicine and culture without laying excessive blame on any single factor or constituency. According to her view, neither genetic disposition, quality of medical care, or Pima dietary behavior is wholly responsible. Honest and productive approaches should view all such factors as interrelated and situated in a broader contextual framework. One example is the tendency for Pima women, including conscientious diabetic women, to abundantly serve and eat fry bread, a highly fatty and caloric flatbread that in contemporary times became a trademark American Indian food in the Southwest and elsewhere. As the author points out, people do not serve and eat fry bread because they think it is healthy. They do so because it is a cultural symbol of such important values as comfort, status, and ethnicity. Another example may be found in the ineffectiveness of medical practitioners' efforts to educate the Pima community about what it means to be at risk of contracting or to have diabetes. Although the medical framework that identifies risk as statistical and the disease in terms of numerical scales may be natural to the health provider community, it is largely foreign to Pima thinking. It is a form of characterization that, while accurate, also may lead to patient reinterpretation and counterproductive behavior.

This highly accessible book makes an important contribution to the literature regarding diabetes among the Pima and, more broadly, regarding chronic non-transmissible diseases in indigenous populations. The emergence of overweight and obesity, diabetes, and cardiovascular disease as ubiquitous health problems in developing societies globally is an insidious problem for healthcare. It also presents a special challenge for indigenous societies in Brazil and other South American countries, where recent socioeconomic transformations are rapidly affecting nutrition profiles. No less in those indigenous societies than among the Pima of the United States, effective strategies for preventing diseases related to diet and behavior are often particularly elusive because local economic and sociocultural realities may differ starkly from those which predominate in surrounding national societies and in the medical communities that serve them. Smith-Morris' treatment of diabetes among pregnant Pima women makes the important point that in such contexts, causal factors are extremely complex and that recognizing that fact may make addressing them in specific local contexts more attainable. Although the scope of the book is narrower than the title implies, it is a revealing local case study with global relevance in the fields of public health, medical healthcare, anthropology, and indigenous studies.