Re-describing Diabetes:Toward A Political Ecology of Health and Bodies

How does a society, a government, or the academy explain away eighteen years? In Arizona, eighteen years marks the disparity between the average life expectancies of American Indians and non-Hispanic whites (Arizona Department of Health Services, 2005; Indian Health Services, 2001). With what technologies and mythologies do we naturalize such a stunning gap? Life expectancies for American Indians are lowest of any population nationwide, and preventable illnesses comprise the majority of the health inequalities that contribute to this picture (Warne, 2006). The diabetes epidemic tops the list, having become the major cause of morbidity and mortality in indigenous communities in the United States (Gohdes 2006). Since the 1970’s when it became recognized as a serious public health issue, rising rates of diabetes and a falling age of onset appear to have become intractable. Young children are being diagnosed with “adult onset” diabetes now, only enlarging the risk for serious health complications in their lifetimes.

Inequalities in the prevalence and experiences with this disease are unambiguous. Incidences in indigenous people exceed 200% of the national average, and some groups are grappling with astonishing rates at 700% the average (Warne 2006). That means for some native communities, half their population is afflicted. And their experiences with diabetes are more agonizing than their non-native counterparts. American Indians are more likely to suffer severe complications associated with adult onset diabetes—ischemic heart disease, retinal failure and blindness, lower limb amputation, kidney failure—and to die prematurely (Gohdes 2006). How we, as citizens, researchers, health workers, policy advocates, politicians, or fellow humans, respond to this health crisis is shaped by how it is narrated.

Critical research fields that articulate social inequalities in health are multiplying.[1] New subfields emerge as scholars couple health with conceptual territories familiar to social or environmental science: culture, urban landscapes, political economy, race, gender, globalization, environmental toxins.* They are producing (literally) vital knowledge. But is this a proliferation of hybrids that never finally resists nature-culture binaries? Do the society-nature couplings in their theoretical titles function by way of one term’s explanation for the other, the way socio-biology and human ecology tend to collapse culture into organicist explanatory frames? Or do they radically re-describe health as a kind of quasi-object, imagined from the beginning as networks of co-constituting processes—material, semiotic, and social?[2] If the practical and ethical impetus of most critical fields for health discourse is to build a social and environmental justice or human rights approach to disease and wellness, how we theorize health and bodies matters.

In my research on indigenous North American experiences with and responses to disproportionate incidences of adult onset diabetes, I encounter another set of critical takes on health. Native counter-discourses are pushing back against disempowering and ahistorical explanations for modern health crises in their communities, and generating comprehensive prevention and treatment strategies aimed at community, culture, relationships with land, sovereignty struggles, public policy, and food economies.

If addressing disease at social-structural or environmental sites seems anomalous, it is likely because we foreclose social, political, and economic strategies and accountabilities for wellness when we imagine an autonomous human body as the provenance for health. Or because we imagine society, culture, the State, and economy happening outside of bodies as a matter of course. That is, we still live by “the Great Divide,” an epistemology that cleaves the world into two: “Nature” [matter-environment-body-feminine-dominated-contingent-ephemeral-object-nonhuman] and its distinct opposite, “Culture” [mind-spirit-soul-masculine-dominant-universal-immutable-subject-human].[3] The disjunction between the social and natural sciences is one example of the many estrangements forged through this mapping of Reality peculiar to “the West.”[4]

In working toward a political ecology of diabetes in Native North American societies, I point to the narrowly defined pathogenesis for this health crisis, an outcome that is attributable in part to the institutionalization of divided knowledge in the academy. Creating accountability for health disparities at the level of government and economy—and nurturing a society that defends disease prevention for all—means interrogating modern dualisms as they have been inherited by academic disciplinarity and dominant cultural narratives about health.

Biomedicine, The Dominant Frame

Biomedicine gives the dominant etiological account for the disproportionality of diabetes rates in indigenous North Americans in two major parts. Most funding resources are poured into genetics research, expounding the “thrifty gene hypothesis.” The theorized gene—never found in the genome—is imputed to all indigenous peoples globally, evolved to protect against times of famine by greedily storing fat when calories are available. Anthropologists and other social scientists have been critical of reified genetic explanations for group health profiles, for whom it vaguely (or clearly) smacks of scientific racism (Sheper-Hughes 2004; Krieger 2001). Does a strictly biological view of race account for the global phenomena of increased rates of diabetes in indigenous peoples in modernizing countries, despite that this category represents a diverse group of peoples from disparate places across the globe? Another way to classify this otherwise diverse group is through common social experiences of displacement, trauma, and social marginalization within an imposed cash economy via colonialism and neocolonialism. Discrete genetic explanations for this health crisis are ultimately ahistorical and disempowering. The etiological focus on genes locates pathology most fundamentally in the bodies of victims, and portrays diabetes as an inevitability for many people, especially Native Americans.

Biologist and feminist theorist, Donna Haraway, has slated “genetic fetishism” as “a non-critical relationship to genetic technologies” and laments the public’s subcritical enthusiasm for projects like human genome mapping where “the gene is seen as the blueprint and makes everything” (1998). By and large, Americans are familiar and comfortable with a narrative of genes as pre-determinants of our bodies and as discrete agents that build Nature. Responding to that pervasive assumption, critical social scientists pointedly caution that the biologization, racialization, and naturalization of illness can and do function as oppressive and violent discourses, especially for marginalized people. Walter Benjamin observed that “under various forms of governance and govermentality [there is] the tendency to ‘normalize’ suffering, disease, and premature death among certain excluded or marginalized classes and populations” (Benjamin, 1968). Michael Taussig describes this as “terror as usual,” and Nancy Sheper-Hughes calls it “everyday violence” (Sheper-Hughes 1992; Taussig 1992). “[V]iolence and disease are linked in [an] ordinary way in social and bureaucratic indifference toward the excess morbidity and mortality of certain populations under the assumption that alarming statistics are not to be seen as alarming at all but rather as ‘normal’ to the population and therefore ‘to be expected’” (Sheper Hughes 2004). When genes and biopathology research monopolize funding and public understanding of elevated incidences of diabetes and its complications in Native North Americans absent social or environmental context, it produces a narrow, racialized, and naturalized narrative that obscures accountabilities outside of the bodies of victims. Yet, genes are decidedly not what have changed since the 1930’s when diabetes was virtually non-existent in indigenous societies in North America.

The secondary etiological account for diabetes in indigenous people looks to diet, nutrition, and exercise. Prevention and treatment initiatives aimed at educating native people about healthy food and lifestyle “choices” are failing to mitigate the stubborn rise in rates of diabetes and the falling age of onset (Warne 2006). Perhaps it is because while food and exercise are not unimportant topics, biomedical researchers and public health workers socially decontextualize and ahistoricize them to the point of victim-blaming. It is the bad habits of the sick that account for a rampant public health crisis. “Food” and “exercise” are deployed narrowly and ethnocentrically. Biomedical experts are not asking what, environmentally or socio-historically, has produced chronically sedentary bodies and created a limited menu in Indian Country of canned meat, packaged, processed and sugary foods, white flour, and lard. They are not asking what has produced extreme poverty, or what structural constraints poverty sets up to restrict healthy diets, bodily movement, and access to healthcare. Their unit of analysis is, primarily, individual bodies deracinated from society, environment, history and their integrations.

Diabetes as an Embodied Political Ecology of Colonialism?

During and in the wake of western expansion, a series of state sponsored projects had the cumulative effect of displacing, dispossessing, decimating, and traumatizing tribes across the American West. With the ambition of subduing the land and putting it to work for the Unites States of America—with the justification that native inhabitants were too benighted to exploit nature properly—they disrupted or extinguished complex cultural-ecological relationships, ecological knowledge systems, traditional food economies, and subsistence practices. Development projects—dam building, massive irrigation and hydrological diversion projects, gold and mineral mining, industrial agriculture—wreaked havoc on the local ecologies of societies in interdependent relationships with them. Sent out to claim “open” land in the name of a providential American government, swarms of white squatters and settlers strained resources and radically altered environments, destroying the basis of complex indigenous economies. Encroachment and environmental degradation persisted despite native struggles to stop the resource thefts and degradations that were destroying their lifeways and communities (Dejong 2011).

Confinement to reservations only further interrupted geographies of subsistence. As the majority of western lands came under federal land management outfits in the 20th century— like the national forestry service and national parks, indigenous people were additionally restricted from their land bases and traditional subsistence practices. In short, these are stories of the production of racialized poverty through resource cooptation. Through state sponsored projects backed by force of military, the resources that provided livelihoods for native peoples were systematically damaged, enclosed, diverted, or appropriated to build a cash economy that generates wealth for non-natives. It is an ongoing storyline. Neglect of treaty rights and land titles persist today, as do government restrictions that prohibit indigenous people from practicing subsistence traditions. GMO technologies are patenting native seed varieties traditionally significant to indigenous tribes, once again diverting the wealth of resources from native to non-native hands.

As a crisis of hunger ensued subsequent to reservation confinement, government commodity food schemes began to dump unhealthy foods onto reservations in order to minimally and cheaply fill bodies that could no longer be fed by traditional food economies. Forced assimilation projects, like Indian Boarding schools, subjugated indigenous knowledge and culture, contributing to the attack on the ability of tribes to reproduce the cultural-ecological relationships that had sustained them. The commoditized food economy that supplanted traditional food economies made calorie-dense nutritionally vacuous foods available in lieu of diverse, locally sourced diets. Bodies that used to have cultural roles as hunters, gathers, basket weavers, gardeners, and food preparers became sedentary consumers. Food as a commodity is itself a novel human-nature configuration that entails many social, environmental, cultural, bodily, and spiritual losses. For many tribes, food is conceived as a web of relations entailing many obligations to human and nonhuman life, not just matter to be consumed.

We are familiar with smallpox and influenza as diseases that wreaked havoc on indigenous peoples as a result of colonialism. Do chronic illnesses, like diabetes mellitus, represent another scourge of colonialism and neocolonialism? Attempting to build better and more integrated theoretical frames for epidemiology, social epidemiologist and Harvard professor of Public Health, Nancy Krieger, employs the term embodiment to capture how we “literally incorporate, biologically, the material and social world in which we live, from conception to death” with the corollary that “no aspect of our biology can be understood absent knowledge of history and individual and societal ways of living” (Krieger 2001). Embodiment sets up a more critical relationship between race and disease. By “[e]mbracing social determinants ignored by biomedical approaches, [a more integrative medical approach] recasts alleged ‘racial’ differences in biology (e.g. kidney function, blood pressure) as mutable and embodied biological expressions of racism” (ibid). When we re-embed biology in social, historical, and environmental contexts, we stop reifying race—thereby reproducing racism—and instead start to hold the institutionalization of racism accountable for social disparities in health.

Toward a Political Ecology of Health and Bodies

Some of the aforementioned research fields critically looking at health have helped me to see a larger picture for this health issue. Yet they present their own limitations. Environmental racism, for instance, points to geographies of unequal resource access and exposures to toxins, illustrating the construction and perpetuation of racism in our built landscapes that result in social disparities in health outcomes and experiences. But this important discourse has yet to become historical, conceptualizing the deeper socio-environmental histories that produce inequality in resource access and wealth in the construction of racial difference. Conversely, critical medical anthropology does provide a framework that highlights the role of socio-cultural histories in shaping wellness, and articulates how political economy patterns health outcomes. However, it lacks theoretical focus on nature-society relationships.

I find that political ecology helps to capture more of these entanglements. And it does more than that. Political ecology is from the beginning a critique of the dualisms upon which (capitalist) modernity hoists itself: human/environment, individual/society, mind(spirit)/matter, human/nonhuman, nature/culture, modern/primitive. Discrete human bodies become embedded in and shaped by environmental and social histories. Bodies, environments, and socio-political structures are not distinct entities to occasionally consider in conjunction, but already co-constitutive.

Genes, then, are not made obsolete by a political ecology of health and bodies. Political ecologists are just less likely to make fetishes of them, a process Haraway describes as “‘forgetting’ that bodies are nodes in webs of integrations, forgetting the tropic quality of all knowledge claims” (1998). She reminds us that “a gene is not a thing, much less a ‘master molecule’ or a self-contained code. Instead, the term gene signifies a node of durable action where many actors, human and nonhuman, meet” ( 1997). What is so ambitious about political ecology is that it avoids collapsing material, narrative, or social actors into one of those categories. Political ecologists try to eschew the facile substitution of social actors for biological ones, because that only reproduces an epistemology that, through its dualisms, is colonizing, patriarchal, alienating, and anthropocentric. Complex crises like public health catastrophes cannot be reduced to either social or natural agencies alone, or to simplistic conjunctions that ultimately reduce one into the other. I see critical health scholarship in anthropology and geography pointing to the violence and injustices of what happens when disease is imputed solely to the latter. But there is more work to do in order to build frameworks that grasp the complex networks that constitute public health calamities, which must include many agencies that otherwise tend to be ontologically privileged either by social or natural scientists— e.g. genes, society, culture, language.

Finally, a political ecology of health and bodies not does take an apolitical stance toward disease and wellness. Political ecology departs from cultural ecology’s politically innocent nature-culture balance model to acutely investigate how political economy shapes inequalities in producing particular socio-natural configurations. Political ecologists of health would ask questions about political accountabilities in social patterns of disease, avoiding the assumption that illness, as an ostensible taxon of “nature,” is not political. Rejecting the possibility for positivistic objectivity in research, it does not shy away from playing a role toward social change.

At the very beginning stages of my ethnographic research, I see Native North American leaders most radically re-describing diabetes as a social, environmental, and bodily disease with an historical context, and to generate comprehensive, decolonizing and cooperative efforts toward recapturing health in their communities. My work is to be in conversation with them, open up lines of dialogue to expand ways of knowing, and to try to articulate the webs that connect this issue to broader conversations about globalization and health, the globalization/commoditization of food, environmental justice, and social inequalities in health.

Janna L. Lafferty

Ph.D. Student, Environmental Anthropology

Department of Global and Sociocultural Studies

Florida International University, School of International and Public Affairs

[1] e.g. Health Geography, the Anthropology of Health, Medical Anthropology, Critical Medical Anthropology, Environmental Health, Environmental Racism, Social Epidemiology, Public Health, Global Health, The Ecology of Illness

[2] Bruno Latour pointed to the problem of our “proliferation of hybrids,” crises whose complexity is denied in our presumption of binary categories. When we cease to invoke “nature” or “culture” as a priori explanatory categories for phenomena, we can instead imagine them quasi objects constituted by traceable networks of human and nonhuman actors, and address them with integrated knowledge (Latour, 1993).

[3] The concomitant divide is between “modern” and “primitive”— what Johannes Fabian called the “denial of coevalness.” This divide locates moderns in a distinctly advanced stage of a universalized notion of history. The rest are rendered “premodern”—anachronisms representing early stages of human development. We locate them closer to Nature than Culture with the configuration that we have Culture and they have cultures. Theirs have not dominated nature. Therefore, they do not convey the same agency as the intellectual accomplishments of moderns—who have ostensibly transcended nature by achieving universal subjectivity. It is also a gendered divide that similarly positions women close to nature via her role as a reproductive apparatus. Her body is marked, and her subjectivity contingent.

[4] In as much as “the West” is a messy, problematic category, its use has relevance here as a construction via processes of colonization, which generated and radicalized these epistemologies of duality in ways that abetted and legitimated European conquest and exploitation across the globe. Edward Said’s work on Orientalism and Arturo Escobar’s work on coloniality, for instance, provide us with meaningful frameworks for invoking “the West.”

References

Arizona Department of Health Services. 2009. Differences in the health status among ethnic groups. Retrieved from http://www.azdhs.gov/plan/report/dhsag/dhsag03/ethnic03.pdf. Phoenix: Arizona Department of Health Services.

Benjamin, Walter. 1968. Illuminations: Essays and Reflections, edited by Hannah Arendt. New York: Schocken.

Dejong, David. 2011. Forced to Abandon Our Fields: The 1914 Clay Southworth Gila River Pima Interviews. Salt Lake City: University of Utah Press.

Gohdes, Dorothy. 1995. “Diabetes in North American Indians and Alaska Natives” In M.I. Hariis, et al (Eds.), Diabetes in America, 2nd ed. Pp: 683-95.

Haraway, Donna. 1997. Modest_Witness@Second_Millennium.Femaleman©_Meets_OncoMouse.™ Feminism and Technoscience. New York: Routledge.

Haraway, Donna and Thyrza Nichols Goodeve. 1998. How Like a Leaf: An Interview with Thyrza Nichols Goodeve. New York: Routledge.

Indian Health Service. 2001. Regional differences in Indian health 2000-2001. Rockville, MD.

Krieger, Nancy. 2001. “Theories for social epidemiology in the 21st century: an ecosocial perspective” International Journal of Epidemiology 30 (4): 668-77.

Sheper-Hughes, Nancy. 1993. Death Without Weeping: The Violence of Everyday Life in Brazil. Berkeley and Los Angeles: UC Press.

Sheper-Hughes, Nancy. 2004. “Foreword” In M.L. Ferreira and G.C. Lang In Indigenous Peoples and Diabetes: Community Empowerment and Wellness. Pp: xvii-xxi. Durham: Carolina Academic Press.

Taussig, Michael. 1993. “Terror as Usual: Walter Benjamin’s Theory of the History as State of Siege” The Nervous System. New York: Routledge.

Warne, Donald. 2006. “Research and Educational Approaches to Reducing Health Disparities Among American Indians and Alaska Natives” Journal of Transcultural Nursing 17: 266