MEDICAL CONSULTATION IN AN AMERICAN INDIAN DIABETES CLINIC

MEDICAL CONSULTATION IN THE INDIAN COUNTRY

I am proud to be a Physician to some Native American Indian tribes.  On this day, this 54 year old Indian came to see me regarding his uncontrolled Diabetes.

To get to the Clinic, he has to walk to the collection point for free transport offered by the hospital and Clinic. It is offered twice daily. The town he lives in is 35 miles north of the Clinic. The winters can be brutal in this part of the world, but he very seldom misses an appointment.

He was born in the Indian village where the clinic is located. He attended an Indian boarding school and then joined his mother who had moved to the town where he still lives. That was in 1975.

He had last worked in 1993, 22 years ago. Alcohol abuse had been a part of his life. He was sentenced to 5 years in prison for domestic violence (he was drunk). He sobered up, like they say, on 13 April 2003 (nearly 12 years ago)

His current “income” is $194 per month in food subsidies provided by the US Government. When he can get a ride, he would shop at Wal-Mart. Otherwise he is forced to buy food at the neighbourhood petrol station (junk Food at higher prices). He lives in a duplex in a poor section of the town, rented by his sister, owned by a Mexican Immigrant. His sister, unemployed, suffers from the complications of Diabetes , with one below Knee Amputation and she is on Dialysis, three times a week. Her boyfriend, also unemployed, takes care of her, helping her reach the Dialysis centre three times a week, using public transport. A nephew who is disabled with a hip injury is also unemployed, 42 years old  also lives at the house. Two nieces also call this small apartment home, one of them is currently incarcerated, the other, also unemployed, leads an itinerant life style, alcohol features predominantly in her life.

No one owns a car. The nearby Church provides clothing donated by charities. He wears XXL shirts and 38 waist pants.

This patient uses his 194 dollars food allowance to buy the following: Eggs, White bread, Cottage Cheese, potted meat, Diet pop, Crystal light powder to make sugary drinks.

Do you eat at Fast Food Restaurants, like McDonalds?

No Way, he laughs, I cant afford it, since I have no money.

I know I should eat better, but I have only 194 dollars in Food allowance to last me one month.

Pleasant gentleman, no resentment towards any one, no gripes, honest, not jealous towards those who has more than him, goes to extra trouble to come to the clinic, with both of us knowing that it is the availability of human warmth that he seeks here, that brings him here. We reciprocate what he gives us and do whatever we can do for him. The least we can do for him, is to make sure that he has enough medications, make sure that his feet are without any dangerous signals of impending ulcers, that his eyes are checked and also to make sure that he gets home safe on the hospital transport.

Why doesn’t his Diabetes come under control? The society has cornered him, he has no access to food, only chemically laden processed food. Medications can combat the effects of Food on his Diabetes but cannot deal with the chemical’s effects on his Diabetes.

He reaches out to us, the nurse educator and the doctor at the Diabetes Clinic, the Family Physician who cares for him in the hospital clinic, he gets to visit some people  he may know at the clinic/hospital, and a day is pleasantly spent, before going back to his lodging, in a city where he garners no value or respect, an alien city with an alien culture.

As he was preparing to leave, something compelled me to take out my wallet, empty it and give the money to him. Believe it or not, he was reluctant to accept but I could see he was happy to have some cash, not food stamps issued by the US Government. He smiled broadly and hurried to catch the hospital transport home.

I thought of 3 women in my life, all three sisters in one way or another who have influenced me and also watch over me.

The Diabetes Educator Nurse puts the welfare of the people like this patient and many many others like him in this isolated, poor country. To me, she personifies what I would call ‘christian” values of the western civilization, non judgmental, all done in the sense of service, with thoughts of relief from pain and suffering in these marginalized original inhabitants of this land.

My Indian sister, an extremely efficient administrator, many years ago , by her actions taught me what it means to be a relative, to the people you work with, the people you come across in your every day life in this poor community of Indians. She also believes that we must have a head to toe approach to our patients, that we must provide the best quality care we are able to provide to each and every Indian who comes to the clinic.

I have to reiterate that these unfortunate souls may be poor in material things but they are not poor in spirits and generosity of themselves.

My British-Jamaican sister has a big heart and as I write this, aboard a flight to Miami, it is she that I am going to see. I am certain she would have prepared some dishes that I like. She knows that I had been in a food desert for the past one week. (PS . I enjoyed the Curried Goat she had prepared, with rice, she has already prepared the breakfast for tomorrow of Jamaican fish fritters and avocado, and always good strong British Brooks Bond Tea)

This past week, Consultation of this sort took place, over and over again. Patients had travelled from far and mostly from the village, most of them wanted to talk, some had problems (not medical but social) which took hours to negotiate with the authorities. As my Indian sister would say: Let us take care of them, head to toe.

The role of Medicine/Medical Care Provider is not limited to diagnosis and treatment but also alleviation of their suffering, not just physical but social, cultural and spiritual.

I am proud to be a Physician to the Indian, the native people of America.

As I pulled into the drive through window of the small bank, the only one in a thirty mile radius, I realized it had closed for the day. So here I was, metaphorically without any money in my person, beginning a pleasant journey to my Miami and Cuban homes and hearts.

May my Mezhinga be blessed with the good spirits of these ancient people.

SUCCESSFUL SOCIAL AND CULTURAL RESEARCH IN HEALTH, ILLNESS AND DISEASE

SUCCESSFUL SOCIAL AND CULTURAL RESEARCH IN HEALTH, ILLNESS AND DISEASE

You have to tip your hats off to molecular scientists who concentrate on a minute aspect of metabolism. But it is that concentration that produces revelations, those results converted down the line into treatments for common and rare disorders.

As a Medical Anthropologist, is there an equivalent to that kind of concentration on small components of everyday life, in our field of observation and research?

Yes!

Observe, participate, assist and share the lives of the same groups of people over a long period of time

When you are thinking of the welfare of a group of people, rather than an individual in a group or working on an instrument or a pharmaceutical drug, the worldview has to be a selfless one. A purity of intentions usually fires the enthusiasm when working for the welfare of a group of people. A Community is not a collection of individuals living in proximity to each other, brought there because of external parameters, such as wealth or education.

I am lucky to be working with American Indians, henceforth referred to as Indians, who have not only a shared culture, history and many a times, a language and a religion but also a collective unconscious, which Carl Gustav Jung was able to codify while watching them.

By describing their lived in experiences and explanatory models of their illnesses, it was evident that the aetiology of their diseases did not and does not fit into the commonly accepted physiological and biochemical explanations.

One has to be a Medical Anthropologist if you wish to understand fully the suffering of a community, regardless of which country they live, Canada or USA or Australia or Aotearoa; only by understanding can you assist in some meaningful help to alleviate that suffering a little bit.

The Cartesian dichotomy of Mind and Body has had a strong influence in the Western Medical thinking, it often asks, What is happening?

And looks for an explanation by objecitivising the symptoms of suffering of the person into physiological dysfunction with a name, Disease: to be measured, treated and followed up, in a strict Quantitative fashion.

An anthropologist may ask a different approach, about the same phenomenon: Why is this happening? Why is this happening now? What alleviates this suffering? What can be done?

Two observations stand out in the context of my first contact with the Indians.

a.     The tribe which once used to be healthy and lean, are now overweight, obese. At the time of contact the white men wondered about the excellent health of the natives. In 300 years, their social, cultural and economic as well as physical situation had deteriorated.

b.     Fortunately enough during my travels among other indigenous peoples of the American Continent, it was curious to observe that these afflictions were rare among the other Indians, who are related to the North American Indians. The Kuna of the Panama had no Diabetes, were not overweight, had no change in Blood Pressure with age.  Many other tribes, in Mexico, Guatemala, Ecuador and Peru, were strangers to the afflictions and suffering of their brothers and sisters to the North.

Obviously then it was not a genetic phenomenon, perhaps an epigenetic phenomenon, even though the concept was not popularized until recent times.

For a social scientist, it was probable that the sufferings of Indians of North America, including Canadian First nation people as well as Australian Aboriginals and Maori of Aotearoa, were the results of social dysfunction caused by maladjustment to another society, culture and not to mention an inferior food product (which was to become clear in the analysis in the new century). It exhibited as Obesity, Diabetes and Hypertension in the body as well as other chronic metabolic problems.

It is interesting to look at the history of these diseases among the Indians. Hrdlicka in his book published in 1908 had mentioned that pathological obesity did not exist among any of the Indian tribes he had encountered. Doctors working with the Navajo exclaimed that they never saw a patient suffering from High Blood Pressure. Even the doyen of Diabetes in America, Dr Joslin, conducing a large number of measurements appropriate for the day, in 1920s, declared that American Indians are free of Diabetes. Records indicated that it was rare for an inpatient at an Indian Hospital to carry a Diagnosis of Diabetes.

Why this dramatic change? In less than fifty years, ninety per cent of the American Indians were overweight or Obese (paradoxically enough the percentage of Obese Indians is greater than Overweight Indians, rather than the other way around, once again challenging the physiological thinking).

It was clear, at least to me, that something was coming from outside: social, cultural and chemical that was the cause of this sudden change in a short period of time. When I mentioned these ideas to my colleagues in the USA, it was ridiculed. (except Dr Mark W who was not practicing Medicine for financial security but out of a desire to be of help to people)

The postgraduate education in Medical Anthropology in London which I definitely needed to acquire tools to understand what was happening to the Indians in the USA, helped me a great deal, allowing me to see the socio cultural aspects of their suffering.

The chemical aspect, something that is inflaming, was that a possibility?

In 2002, I was wandering around the streets of Johor Bahru in Malaysia, after a delicious south Indian meal while being on a stopover in Singapore.

A temple in the centre of town advertised a book fair was in progress. I entered the sacred grounds with no expectations. Instead of a cacophony of religious ministrations and philosophical outpourings it was surprising to find all sorts of books on sale. In one corner, a stall had lots of booklets, the kind that would fit into a shirt pocket but their titles were tantalizing.

American Indians would say: things happen for a reason, it is just we are not smart enough to figure out why.

Toxics in Plastics, exclaimed one booklet which I began reading. It was an eye opener, explaining the various ingredients used in various types of plastics that we use in everyday life and their ill effects.

Reading extensively on the already available medical literature, it became clear that,

a.     The knowledge that outside chemicals in the form of plastics causing damage to the body was not something new

b.     While it was not suppressed, it was not being publicized or released for mass consumption for the media. A generation of babies were being exposed to BPA in their feed bottles!

The conclusion, now more than ten years ago,

a.     Chemicals enter the body usually in the form of some additive in “food”

b.     Their chemical composition or metabolism was not discussed, but quantitative biological measures, such as Protein, Fat, Carbohydrate content were being used to hide the chemical nature.

The best example was High Fructose Corn Syrup. With an excess of corn to get rid of, with biological alteration of molecules, HFCS was created, touted as the healthy alternative to Table Sugar, while having very similar content of Fructose and Sucrose.

Here is a conversation with my erudite colleague, Dr Mark W

On 6 January 2015 , "So we speculate that the different sugars could favor different microbes in the guts of mice. Other research has shown differences in bacterial communities in the gut to be associated with metabolic diseases in rodents and humans. It's possible one form of sugar causes more bacteria to get across your gut than another."

The difference between high-fructose corn syrup and sucrose

While high-fructose corn syrup and sucrose contain around the same amounts of fructose and glucose, there is a difference in how they are arranged molecularly.

In corn syrup, fructose and glucose are separate molecules, known as monosaccharides, whereas in sucrose the two sugars bond chemically to form a disaccharide compound

Dr Mark W

Interesting. I wonder if the absorption of the monosaccharides in corn syrup is faster and more likely to produce an insulin spike then the absorption of the sugars from sucrose once the molecule has been cleaved?

Do you have any facts or opinions on this?

Dr Sudah Yehuda KS:

my gut feeling is, pardon the pun, corn syrup acts in a different way than the physiological way that  table sugars are metabolized. I am sure you are able to find some information on that since you can understand it better. (biochemically)

25 % of obese people have no metabolic abnormality. And when they are fed a McDonalds diet, nothing bad happens to them, but in those obese people with metabolic abnormalities the same diet makes everything worse

a susceptibility as well, then.

For example, American Indians as a whole are susceptible to obesity with the kind of diet , so far different than their genetic diet.

When i hear now about a new combination medication for diabetes it does not interest me since the physiology of the diabetes and many inflammatory diseases is what we are after and not the age old physiology which may have been correct as an end product but not as an aetiology.. like they taught us that in  type 2 diabetes the insulin is not effective..in the medical school.

c.     Inflammatory molecules produced directly or indirectly (directly: reaction in the cells on contact or metabolism; Indirectly: secondarily by increasing fat cells or other cells which then produce inflammatory molecules), can give rise to :

Abdominal fat deposition

Fat storage elsewhere  such as the Liver

Act as Endocrine Disrupting chemicals, interfere with the action of the various hormones, such as Insulin, Cortisol, Testosterone and Oestrogen, among others.

The latest addition to this knowledge is the research published just two days ago from Dr Moynagh and colleagues from Maynooth University. My hats off to them.

They have discovered a protein called PELLINO 3 that may block obesity driven inflammation

inflammation and thus prevent insulin resistance and diabetes. According to the researchers, there is a direct correlation between low levels of Pellino 3 in obese individuals. This low level of Pellino 3  is associated with the production of a critically important pro-inflammatory protein called IL-1 that drives inflammation and ultimately Diabetes.

So, as you can see, consistent social observation of the same group of people over a period of time can lead to a good understanding of their suffering and arrive at conclusions later on validated by science.

This can be used to tailor the education, couched in cultural terms and historical information. Indians have a great respect for their ancestors, and of course the ancestral diet is not the one that made them sick.

I am convinced that Medical Anthropology or an Anthropological education is necessary to people who are suffering from maladies of maladaptation in everyday life.

I wish to thank my Indian teachers  Pat B of Meskwakia, Pierre M of the UmonHon and my colleagues, especially the PHNs I have worked with over the years at the various Indian Clinics in the USA.

And to  Dr Mark W